UCICCM  LIBRARY 

CALIFORNIA  COLLEGE  OF  MEDICINE 


ORTHOPEDIC  SURGERY 


BY 


EDWARD   H.  BRADFORD,  M.D. 

Consulting  Surgeon  to  the  Children's  Hospital,  Boston,  and  to  the  Boston  City  Hospital; 
Professor  of  Orthopedic  Surgery  Emeritus  in  Harvard  University 


AND 


ROBERT  W.  LOVETT,  M.D. 

Professor  of  Orthopedic  Surgery  in  Harvard  University; 

Surgeon  to  the  Children's  Hospital,  Boston; 
Surgeon-in-chief  to  the  Massachusetts  Hospital  School,  Canton 


FIFTH   EDITION 
PROFUSELY  ILLUSTRATED 


NEW  YORK 
WILLIAM   WOOD   AND   COMPANY 

MDCCCCXV 


COPYKIGHT,    1915, 
BY 

WILLIAM   WOOD  AND  COMPANY 


wi 

I?    7'H 


HAHWAY,    II.    .. 


TO 

FRITZ  LANGE 
Professor  of  Orthopedic  Surgery  in  the  University  of  Munich 

IN 
Token  of  Friendship  and  Respect 


PREFACE. 

t 

o 

THE  progress  of  Orthopedic  Surgery  is  such  that  more  or  less 

V)  frequent  revisions  of  a  text-book  are  necessary,  in  order  to  make  it 
representative  of  the  specialty. 

In  the  present  edition  the  writers  have  endeavored  to  present  the 
new  and  approved  matters  that  have  developed  since  the  edition  of 
1911  was  printed  and  have  omitted  certain  others  the  consideration 
of  which  no  longer  seemed  necessary.  The  scope  of  the  present 
edition  is  practically  the  same  as  that  of  1911,  and  brevity  has 
been  studied  at  the  expense  of  omitting  references  and  the  extended 
discussion  of  the  views  of  other  writers,  especially  upon  contro- 
versial subjects. 

The  writers  would  again  state  that  this  is  done,  not  in  a  spirit 
of  ignorance  or  disparagement  of  the  work  of  others,  but  simply  in 
the  need  of  condensed  statement. 

E.  H.  BRADFORD. 
R.  W.  LOVETT. 
Boston,  September,  1915. 


22318 


PREFACE  TO  THE  FIRST  EDITION 


THE  writers  of  previous  works  on  Orthopedic  Surgery  have  confined 
themselves  to  a  consideration  of  the  treatment  of  existing  deformities, 
such  as  club-foot,  lateral  curvature,  and  bow  legs.  The  only  conspicuous 
exception  to  this  is  found  in  the  excellent  book  of  Dr.  Sayre.  But  the 
term  Orthopedic  Surgery,  if  it  is  properly  defined,  should  include  the 
prevention  as  well  as  the  cure  of  deformity.  For  this  reason  the  dis- 
eases of  the  joints  have  been  considered  by  us  at  considerable  length, 
inasmuch  as  they  are  among  the  most  common  sources  of  deformity 
and  disability. 

We  have  endeavored  throughout  to  include  such  subjects  as  are 
likely  to  come  to  the  attention  of  those  who  interest  themselves  in  the 
practice  of  this  branch  of  surgery,  without  perhaps  adhering  too  closely 
to  the  definition  of  the  term  Orthopedic  Surgery.  In  this  way,  besides 
the  consideration  of  joint  disease  and  Pott's  disease,  we  have  added 
a  brief  description  of  some  disabling  and  deforming  nervous  affections, 
which  we  have  only  attempted  to  discuss  in  their  practical  surgical 
aspect.  The  deformities  resulting  from  fractures,  dislocations,  and 
burns  are  so. fully  treated  in  works  on  general  surgery  that  they  have 

not  been  considered  here. 

EDWARD  H.  BRADFORD. 

ROBERT  W.  LOVETT. 
BOSTON,  May  15th,  1890. 


CONTENTS. 


CHAPTER   I. 

PAGE 

TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS         .         ,         .         i 

CHAPTER   II. 
TUBERCULOUS  DISEASE  OF  THE  SPINE 8 

CHAPTER   III. 
TUBERCULOUS  DISEASE  OF  THE  HIP _ 

CHAPTER    IV. 
TUBERCULOUS  DISEASE  OF  THE  KNEE QI 

CHAPTER   V 
TUBERCULOUS  DISEASE  OF  THE  ANKLE  AND  OTHER  JOINTS    .         .      IO5 

CHAPTER   VI. 

INFECTIOUS  OSTEOMYELITIS — INFECTIOUS  SYNOVITIS  AND  ARTHRITIS     114 

CHAPTER   VII. 
ARTHRITIS  DEFORMANS 122 

CHAPTER   VIII. 
OTHER  AFFECTIONS  OF  THE  BONES  AND  JOINTS       ....      140 

CHAPTER   IX. 
THE  DEFORMITIES  OF  RICKETS          .......     177 

CHAPTER   X. 
COXA  VARA  AND  COXA  VALGA 2OI 

ix 


CONTENTS 
CHAPTER   XI. 

FACE 

LATERAL  CURVATURE  OF  THE  SPINE 212 

CHAPTER    XII. 
OTHER  DEFORMITIES  OF  THE  SPINE  AND  THORAX  ....      243 

CHAPTER    XIII. 
TORTICOLLIS       ...........      256 

CHAPTER   XIV. 
INFANTILE  PARALYSIS        .........      267 

CHAPTER    XV. 
SPASTIC  AND  OTHER  PARALYSES       .......      301 

CHAPTER    XVI. 
FUNCTIONAL  AFFECTIONS  OF  THE  JOINTS — UNILATERAL  ASYMMETRY     318 

CHAPTER    XVII. 
CONGENITAL  DISLOCATIONS        ......  .     323 

CHAPTER    XVIII. 
TALIPES,   CONGENITAL  AND  ACQUIRED  ;  CLUB  HAND       .         .         .      349 

CHAPTER    XIX. 
FLAT-FOOT     ...........         381 

CHAPTER    XX. 
METATARSALGIA  AND  OTHER  DEFORMITIES  OF  THE  FOOT  399 


ORTHOPEDIC   SURGERY. 

CHAPTER  I. 

TUBERCULOUS   DISEASE   OF    THE   BONES  AND  JOINTS. 

ORTHOPEDIC  surgery  deals  with  the  prevention  and  correction  of 
deformity,  and  demands  not  only  a  study  of  the  deformities  of  the 
human  body,  but  also  some  knowledge  of  the  affections  which  produce 
them.  Of  these  the  most  important  are  the  tuberculous  diseases  of 
the  joints. 

PATHOLOGY. 

Articular  tuberculosis  begins  usually  as  an  affection  of  the  spongy 
tissue  of  the  epiphysis,  or  in  the  juxta-epiphyseal  and  adjacent  region 
of  growing  bone. 

The  common  form  of  tuberculous  infection  of  the  epiphysis  is  the 
one  spoken  of  as  focal,  when  the  first  change  is  the  formation  of  single 
or  multiple  foci  of  tuberculous  degeneration.  On  section  of  the  dis- 
eased epiphysis  the  first  noticeable  change  consists  of  a  local  hyperaemia 
of  some  part  of  the  spongy  tissue. 

From  the  stage  of  tuberculous  infiltration  the  process  may  follow 
any  one  of  three  courses :  the  diseased  focus  may  be  absorbed  and  so 
cured;  it  may  extend  to  the  periphery  of  the  bone  and  break  through 
the  periosteum  and  empty  itself  there:  or,  lastly  and  probably  most 
commonly,  it  may  extend  to  the  joint,  which  becomes  involved. 

1.  The  absorption  of  the  diseased  focus  is  theoretically  possible  up 
to  a  late  stage  in  the  process,  so  long  as  the  disease  remains  strictly 
local. 

2.  The  next  most  favorable  termination  to  the  disease  is  when 
the  focus  does  not  infect  the  joint,  but  breaks  through  the  periosteum 
and  discharges  into  the  periarticular  structure. 

3.  Usually  after  extensive  involvement  of  the  epiphysis  an  arthritis 
results,  with  attendant  injury  to  the  joint. 

Repair  is  brought  about  by  the  formation  of  fibrous  tissue,  proba- 


2  ORTHOPEDIC  SURGERY 

bly  arising  from  the  layer  of  non-tuberculous  granulation  tissue  which 
grows  into  and  replaces  the  tuberculous  material.  Caseous  material 
is  largely  absorbed,  and  the  inspissated  remainder  is  replaced  by  fibrous 
tissue  or  is  calcified  and  encapsulated.  Fibrous,  cartilaginous,  or  bony 
ankylosis  may  result  from  the  process  of  repair. 

It  is  most  important  to  note  that  the  process  of  repair  may  be 
incomplete,  and  that  small  areas  of  tuberculous  material  encapsulated 
by  fibrous  tissue  may  persist  for  a  long  time  and  under  certain  condi- 
tions (i.e.,  trauma,  or  imperfect  hygiene)  may  become  active  and 


FIG.   T. — Tuberculous  Epiphysis.     Vertical  section  through  the  head  of  the  radius,  a.   Shaft  of 

radius;   -b.    epiphyseal    cartilage;    c,    epiphysis;    d,   joint    surface;    cartilage;    c,  tuberculous 

primary    focus;    f,    perforation    of   joint    cartilage    and    infection    of   joint;    g,  tuberculous 
"  pannus  "  extending  over  joint  cartilage.     (Xichols. ) 

cause  a  recurrence  of  the  disease.  Or  the  repair  may  be  complete 
and  the  previously  inflamed  tissue  be  converted  into  cicatricial  bone — 
usually  more  firm  than  the  original  structure. 

\Yhile  synovial  tuberculosis  undoubtedly  exists  as  a  primary  affec- 
tion, in  a  large  majority  of  cases  of  tuberculous  arthritis  the  affection 
arises  in  the  bone. 

Cold  Abscesses. — If  the  tuberculous  process  in  the  bone  reaches 
the  surrounding  tissues  by  perforation  of  the  cortex  and  periosteum 
or  by  rupture  of  the  joint  capsule,  an  abscess  is  likely  to  occur.  The 
area  of  tuberculous  softening  in  the  periarticular  tissues  is  formed  by 
the  coalescence  and  caseation  of  tubercles.  Surrounding  the  softened 
area  is  a  layer  of  tuberculous  tissue,  about  which  is  another  layer  of 
oedematous  and  vascular  granulation  tissue.  This  process  may  extend 
until  a  large  cavity  has  been  formed. 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS      3 

The  contents  of  these  abscesses  are  composed  of  caseous  material 
from  the  degeneration  of  the  tubercles  and  exuded  serum  with  necrotic 
pieces  of  bone.  In  the  fluid  are  polymorphonuclear  leucocytes,  often 
taking  up  little  or  no  stain  on  cover  slips.  Pyogenic  organisms  are 
absent  unless  present  by  secondary  infection.  The  fluid  may  be  like 
true  pus;  it  may  be  so  thick  that  it  will  hardly  flow;  it  may  be  thin 
and  watery  and  contain  coagula,  or  it  may 
be  red  or  brownish  from  hemorrhage. 
Microscopically  tubercle  bacilli  may  be 
found  in  the  abscess,  but  they  are  to  be 
identified,  even  after  prolonged  search,  in 
only  about  one-third  of  the  cases.  In  such 
cases  inoculation  experiments  must  be  re- 
lied upon  to  establish  their  presence. 

The  wall  of  these  abscess  cavities  is 
composed  of  an  inner  layer  of  tuberculous 
tissue,  outside  of  which  is  a  layer  of  sec- 
ondary inflammatory  tissue.  The  inner 
layer  may  be  granular  or  necrotic  and 
ulcerated.  The  abscess  extends  by  periph- 
eral enlargement  in  the  line  of  least  re- 
sistance. The  walls  of  tuberculous  sinuses 
consist  of  an  inner  layer  of  tuberculous 
tissue,  outside  of  which  is  a  zone  of  cedematous  granulation  tissue. 

Instead  of  forming  a  "  bone  abscess  "  the  process  may  result  in 
the  formation  of  a  sequestrum  composed  of  necrotic  trabeculae  retain- 
ing their  shape  and  lying  in  a  cavity  in  the  bone.  About  the  sequestrum 
is  a  layer  of  granulation  tissue.  The  sequestrum  may  take  the  shape 
of  a  wedge  having  its  base  toward  the  joint,  in  which  case  it  is  known 
as  a  "  bone  infarct." 


FIG.  2. — Tumor  Albus.  Small  focus 
in  upper  epiphyseal  line  of  tibia. 
Synovitis  of  joint,  but  no  tuber- 
culous proc-ss  apart  from  focus 
as  noted.  Death  from  miliary  tu- 
berculosis, a,  Epiphysis.;  b,  pri- 
mary focus;  c,  shaft.  (Nichols.) 


ETIOLOGY. 

Heredity. — That  heredity  is  a  factor  in  causing  tuberculous  joint 
disease  has  long  been  claimed.  Whether  the  tuberculous  virus  can  be 
directly  transmitted  as  such  from  father  or  mother  to  the  offspring 
must  still  be  held  open  to  question,  but  that  the  surroundings  of  certain 
families  weaken  the  resistance  and  favor  tuberculous  invasion  appears 
not  improbable. 

Traumatism. — Experimentally  it  has  been  shown  that  trauma  to 
the  joint  of  a  tuberculous  animal  may  cause  tuberculous  joint  disease, 


4  ORTHOPEDIC  SURGERY 

but  that  it  does  not  do  so  in  the  healthy  animal.  It  has  been  estab- 
lished that  contusions  and  wrenches  cause  the  effusion  of  blood  in  the 
spongy  tissue  of  the  bone.  It  would  therefore  seem  rational  to  assume 
that  trauma  may  cause  tuberculous  joint  disease  in  children  with  a 
tuberculous  tendency. 

The  fact  that  there  is  a  preponderance  of  joint  tuberculosis  in  the 
lower  extremity  when  contrasted  with  the  joints  of  the  upper  points 
to  the  influence  of  slight  traumatism  and  weight-bearing  as  factors  in 
the  development  of  the  affection. 

It  is  probable  that  whatever  continuously  diminishes  the  power  of 
resistance  and  of  repair  in  growing  children  increases  what  may  be 
termed  the  vulnerability  of  the  epiphyses,  and  furnishes  the  soil  for 
the  development  of  tubercle  bacilli  and  the  consequent  results. 

Age. — Tuberculous  joint  disease  is  pre-eminently  a  disease  of 
childhood.  It  is  not  congenital,  and  under  one  year  it  is  not  common. 
The  majority  of  cases  occur  between  three  and  ten  years  of  age,  but 
the  liability  of  the  aged  to  tuberculous  joint  disease  must  not  be  over- 
looked. 

The  reasons  why  tuberculous  joint  disease  affects  children  to  so 
great  an  extent  are  as  follows : 

In  the  active  period  of  growth  more  change  is  going  on  and  there- 
fore more  instability  exists  and  consequently  greater  liability  to  disease. 
Children  are  more  liable  to  falls  and  injuries,  which  are  such  a  fertile 
source  of  joint  and  bone  lesions.  It  is  not  till  after  puberty  that  the 
process  of  natural  selection  has  eliminated  the  weaklings  from  the 
stock.  Children  are  kept  quiet  less  easily  than  adults,  and  a  slight  in- 
jury may  develop  into  a  formidable  disease.  Tuberculosis  in  general 
is  common  in  childhood. 

Sex  is  not  a  factor  of  any  prominence,  but  there  is  a  slightly 
larger  proportion  of  tuberculous  joint  disease  among  boys  than 
among  girls. 

Distribution  of  Chronic  Tuberculous  Joint  Disease. — The  relative 
frequency  with  which  tuberculosis  attacks  the  various  joints  in  children 
may  be  estimated  from  the  following  figures : 

At  the  Children's  Hospital,  from  1869  to  1914  inclusive,  8,304 
cases  of  tuberculosis  of  the  joints  were  distributed  as  follows :  spine, 
3,840;  hip,  3,192;  knee,  659;  ankle,  559;  elbow,  54.  These  prac- 
tically all  occurred  in  children  under  the  age  of  twelve. 

In  2ii  cases  of  joint  tuberculosis  among  the  out-patients  occurring 
in  children  under  two  years,  there  were  120  cases  of  Pott's  disease, 
61  of  hip  disease,  and  29  of  tuberculosis  of  the  knee-joint. 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS      5 

In  joint  disease,  when  one  or  more  articulations  are  involved,  any 
combination  may  be  found ;  but  the  most  common  are  hip  disease  and 
Pott's  disease,  knee  disease  and  Pott's  disease,  and  double  hip  disease. 
Disease  of  the  knee-  and  hip-joint  at  the  same  time  is  not  common, 
and  double  tumor  albus  is  unusual. 

DIAGNOSIS. 

The  recognition  of  tuberculous  joint  disease  is  to  be  based  upon 
certain  general  phenomena  modified  by  the  anatomical  conditions  of 
the  joint  affected.  These  diagnostic  signs  are  considered  in  connection 
with  the  individual  joints. 

The  use  of  tuberculin  as  a  means  of  diagnosis  is  sometimes  of 
assistance.  It  must  be  remembered,  however,  that  the  majority  of 
individuals,  at  some  time  or  other,  have  been  tuberculous.  The  use 
of  tuberculin  subcutaneously  is  only  valuable  if  pushed  to  the  point 
of  local  reaction,  that  is,  if  the  dose  be  increased  until  the  diseased 
joint  becomes  painful  or  local  acute  symptoms  come  on.  Such  a 
proceeding,  although  apparently  reliable,  is  obviously  attended  by 
risk  of  doing  local  damage. 

The  skin  reaction  of  Von  Pirquet  has  been  found  to  be  fairly 
reliable  in  children  under  twelve  when  negative.  A  positive  reaction 
is  less  reliable  and  may  be  caused  by  enlarged  lymph  nodes  and 
other  foci  not  connected  with  the  disease.  But,  a  negative  reaction, 
in  the  presence  of  suspected  bone  tuberculosis,  has  been  found  at 
the  Children's  Hospital  to  be,  in  the  great  majority  of  cases,  evi- 
dence either  that  the  patient  is  overwhelmed  by  the  toxin  of  tuber- 
culosis or  that  the  lesion  in  the  joint  is  not  tuberculous.1  The 
great  frequency  of  tuberculous  invasion  has  been  shown  by  the 
autopsies  of  Babes,  for  example,  who  found  lesions  of  the  bronchial 
glands  in  more  than  one-half  of  his  autopsies  on  children;  and  those 
of  Naegeli,  who  found,  in  508  consecutive  autopsies,  that  97  to  98 
per  cent  showed  evidences  of  tuberculosis.  Under  these  circum- 
stances tuberculin  must  necessarily  be  unreliable  in  demonstrating 
joint  tuberculosis. 

The  inoculation  of  material  from  suspected  joints  into  guinea- 
pigs  forms  a  reliable  means  in  the  diagnosis  of  tuberculosis  of  the 
joints. 

The  x-ray  is  an  aid  in  the  diagnosis  of  joint  tuberculosis  where 
the  process  is  sufficiently  advanced  to  have  caused  the  absorption  of 
lime  salts  in  the  affected  area  or  to  have  destroyed  any  part  of  the 
Robertson:  Boston  Medical  and  Surgical  Journal,  1914,  clxx,  p.  550. 


6  ORTHOPEDIC  SURGERY 

bony  structure.     In  early  cases  the  radiograph  may  be  normal  when 
disease  is  present. 

PROGNOSIS. 

The  destructive  process  which  is  so  prominent  a  feature  of  joint 
tuberculosis  is  almost  from  the  first  accompanied  by  a  reparative 
process  tending  to  limit  the  destruction,  protect  the  surrounding  tis- 
sues, and  prevent  generalization.  The  prognosis  depends  in  the  in- 
dividual case  upon  which  of  these  two  processes  prevails  over  the 
other.  The  former  is  favored  by  inefficient  local  treatment,  bad  in- 
heritance, poor  general  condition,  unfavorable  surroundings,  and,  in 
general,  what  may  be  termed  poor  resistance  to  the  tuberculous 
process.  The  reparative  process  is  favored  by  the  reverse  of  these 
conditions.  In  the  majority  of  all  cases  of  joint  tuberculosis,  properly 
treated  at  a  fairly  early  stage,  the  outlook  is  favorable.  The  prog- 
nosis is  more  favorable  in  children  than  in  adults. 


TREATMENT. 

Since  bone  tuberculosis  has  been  shown  to  be  one  manifestation 
of  tuberculous  infection  and  not  the  result  of  an  unknown  evil,  the 
principles  of  treatment  are  more  clear. 

Resistance  to  the  infection  by  the  tubercle  bacillus  is  furnished 
when  the  individual  is  in  a  normal  state.  The  antidotes  to  be  relied 
upon  to  check  its  advance  after  it  has  found  lodgment  are  not  only 
good  aid  and  food,  but  such  general  activity  as  will  promote  normal 
metabolism.  Tuberculosis  is  prevalent  and  fatal  among  caged  ani- 
mals— a  fact  which  is  to  be  borne  in  mind  in  the  treatment  of  bone 
tuberculosis. 

The  treatment  is  both  general  and  local.  The  general  treatment 
consists  in  giving  the  patient  the  best  possible  environment  and  in 
furnishing  such  conditions  that  normal  activity  will  cause  the  least 
possible  injury  to  the  part  locally  affected.  Treatment  by  immuniza- 
tion through  the  repeated  injection  of  tuberculin  is  as  yet  of  un- 
proved value. 

In  tuberculosis  of  the  lung  the  patient  is  in  constant  danger  of 
self-infection  or  increase  of  the  process  from  the  inhalation  of  in- 
fected material;  but  in  bone  tuberculosis  no  such  danger  exists. 
Strong,  well  ossified  bone  does  not  offer  suitable  soil  for  the  bacillus, 
for  bone  tissues  when  invaded  resist  the  advance  of  tuberculous  in- 
fection by  surrounding  the  diseased  area  with  a  thick  enveloping  mass 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS        7 

of  tissue  and  by  subsequently  repairing  the  invaded  region  by  the 
development  of  strong  bone.  Traumatism,  which  injures  this  bone 
construction  and  furnishes  undeveloped  cells  instead  of  firm  bony 
structure,  favors  the  spread  of  the  tuberculous  process.  The  treat- 
ment of  bone  tuberculosis,  therefore,  consists  in  promoting  such  gen- 
eral conditions  as  will  favor  repair  (general  treatment)  and  the  pro- 
tection of  the  parts  from  injury  during  the  disease  (local  treatment). 

General  Treatment. — The  patient  should  be  placed  in  the  most  fa- 
vorable environment  available  in  the  matter  of  food,  home  surround- 
ings, air,  sunlight,  proper  clothing,  exercise,  avoidance  of  fatigue, 
and  similar  requirements. 

OUTDOOR  TREATMENT. — Of  these  requirements  outdoor  air  is  of 
the  utmost  importance,  and  the  open-air  treatment  of  surgical  tuber- 
culosis is  nowhere  more  beneficial  than  in  joint  disease.  The  outdoor 
method  recognized  as  of  such  value  in  the  treatment  of  pulmonary 
tuberculosis  is  advisable. 

In  addition  to  outdoor  treatment,1  the  value  of  sunlight  (helio- 
therapy) has  been  recognized  as  of  value.  This  method  of  treat- 
ment consists  either  in  the  exposure  of  the  affected  part  to  the  rays 
of  the  sun,  or  by  the  exposure  of  the  whole  body.  The  relative 
merits  of  the  two  methods  have  not  been  settled.  It  is  being  recog- 
nized in  America  that  a  convalescent  home  in  the  country  is  an 
almost  necessary  part  of  a  surgical  hospital  for  children. 

Local  Treatment. — Fixation,  distraction,  and  protection,  along 
with  operative  treatment,  are  considered  in  speaking  of  the  individual 
joints. 

1  Lovett  and  Fish:  Outdoor  Treatment  of  Surgical  Tuberculosis.  Boston  Medical 
and  Surgical  Journal,  1913,  clxix.,  p.  145. 


CHAPTER  II. 


TUBERCULOUS   DISEASE  OF  THE  SPINE. 

Definition. — Pott's  disease  is  the  name  applied  to  a  destructive 
pathological  process  which  attacks  the  bodies  of  the  vertebras.  It  is 
also  called  caries  of  the  spine  and  angular  curvature. 

PATHOLOGY. 

Pott's  disease  represents  the  result  of  a  destructive  ostitis  affecting 
the  spongy  tissue  of  one  or  more  of  the  vertebral  bodies.  This  ostitis 

is  tuberculous  in  type  and  fol- 
lows the  same  course  as  tuber- 
culous ostitis  occurring  at  the 
epiphyses  of  the  long  bones,  as 
in  hip  disease,  tumor  albus,  etc. 
The  focus  of  tuberculous 
material  may  either  be  absorbed 
or  calcified,  or  as  happens  much 
more  commonly,  the  ostitis  may 
increase  until  it  has  destroyed 
a  large  part  or  the  whole  of  a 
vertebral  body.  In  its  course 
of  enlargement  it  may  include 
portions  of  bone,  the  nutrition 
of  which  is  cut  off  by  the  adja- 
cent inflammatory  destruction; 
which  portions  necessarily  be- 
come necrosed,  and  with  case- 
ous matter,  granulation  tissue, 
and  the  products  of  inflamma- 
tion constitute  an  area  of  al- 
tered and  degenerated  struc- 
ture in  the  vertebral  body. 
If  this  diseased  area  has  be- 
come large  enough,  the  vertebral  body  gradually  becomes  incapable 
of  sustaining  as  much  pressure  as  before.  From  the  peculiar  weight- 

8 


FIG.  3. — Lower  Dorsal  Region.  Opposite  half  of 
specimen  rested  on  knuckle  while  hardening, 
so  that  gravity  extended  the  spine.  Marked 
separation  of  diseased  vertehrx.  n,  Tuberculous 
disease  beneath  prevertebral  ligaments;  b,  cav- 
ity between  diseased  vertebrx.  (Xichols. ) 


TUBERCULOUS  DISEASE  OF  THE  SPINE  9 

bearing  function  of  the  vertebral  column,  the  pressure  upon  each 
vertebral  body  is  always  considerable  when  the  vertebral  column  is 
in  the  erect  position.  If  one  vertebral  body  is  becoming  excavated,  a 
point  will  be  reached  where  it  can  no  longer  sustain  the  weight,  but 
must  give  way  slowly  or  suddenly.  A  forward  tilt  of  the  whole  ver- 
tebral column  above  the  seat  of  disease  is  then  inevitable,  with  a  cer- 


FIG.   4. — Sagittal   Section   of   the   Spine   from    the   9th    Dorsal   to  the   znd   Lumbar.     Compression 
of  cord  and  abscess.      (Schulthess.) 

tain  amount  of  backward  angular  deformity  at  the  diseased  vertebra. 
This  is  the  mechanism  of  the  production  of  the  knuckle  in  the  back. 

This  process  is  limited,  as  a  rule,  to  the  vertebral  bodies;  the  trans- 
verse, articular,  or  spinous  processes  are  rarely  affected  secondarily 
or  primarily,  their  structure  of  hard  bone  apparently  protecting  them 
from  tuberculous  invasion.  The  intervertebral  cartilage  between  the 
diseased  vertebrae  becomes  disintegrated  and  disappears. 

There  may  be  two  or  more  foci  in  one  vertebra,  or  the  whole  body 
may  be  equally  affected;  the  disease  may  be  limited  to  one  spot, 


10 


ORTHOPEDIC  SURGERY 


forming  a  localized  abscess  of  the  bone,  or  it  may  extend  so  as  to 
involve  the  adjacent  vertebra,1.  If  the  disease  remains  limited  to  the 
centre  of  the  vertebra,  but  little  deformity  may  result. 

In    certain    cases    the    formation    of    tuberculous    detritus    is    a 
characteristic  of  the  disease  from  the  first,  and  in  these  cases  abscesses 

are  apt  to  be  a  conspicuous  feature.  The 
tuberculous  pus  finds  its  way,  during  or 
after  the  destruction  of  the  body  of  the 
vertebra,  into  the  surrounding  tissues  and 
gravitates  downward.  It  appears  usually 
in  the  course  of  the  sheath  of  the  psoas 
muscle  when  the  disease  is  situated  in  the 
lower  half  of  the  spine,  but  the  site  of  the 
abscess  necessarily  depends  upon  the  place 
of  the  original  disease,  and  may  be  in  the 
mouth — as  in  retropharyngeal  abscess — 
in  the  neck,  in  the  axilla,  or  in  the  back, 
lungs,  abdomen,  or  groin.  The  contents 
of  such  abscess  as  a  rule  contain  no  pyo- 
genic  bacteria. 

Paralysis. — In  certain  cases  menin- 
gitis and  myelitis  are  present  in  the  cord 
opposite  the  seat  of  disease,  accompanied 
sometimes  by  what  is  virtually  the  de- 
struction of  the  cord  at  that  point.  The 
paralysis  is  very  rarely  caused  by  direct 
pressure  of  bone,  as  it  is  uncommon  for 
even  very  marked  deformities  of  the  spine 
to  narrow  the  spinal  canal  to  any  great 
extent.  Many  cases  with  extreme  de- 
formity are  never  paralyzed  at  all. 

In  proportion  to  the  extent  of  the  dis- 
ease and  the  number  of  vertebrae  in- 
volved, an  angular  deformity  of  the  spine 
may  be  present  to  any  extent.  In  severe 
cases  this  angular  deformity  leads  to 
secondary  pathological  changes. 
The  shape  and  capacity  of  the  chest  are 
necessarily  very  much  altered,  and  the  ribs  sometimes  sink  into  the 
pelvis.  As  a  result  of  these  changes  in  chest  capacity,  hypertrophy 
of  the  heart,  often  accompanied  by  valvular  disease,  is  common.  The 


—  a 


FIG.  5. — Distortion  of  Aorta.  From 
a  case  of  spinal  caries  in  an  adult. 
At  one  point  marked  constriction 
of  the  aorta.  Angular  deformity 
very  marked.  a,  Constriction  of  many 
aorta.  (Dwight. ) 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


II 


aorta  may  be  distorted  as  a  result  of  the  deformity.  Dwight  reports 
a  case  in  which  its  course  "  might  be  compared  to  an  S  lying  on  its 
side,  with  the  ends  bent  strongly  back  to  fit  around  the  prominence 
of  the  spine."  Lannelongue  found  a  very  marked  narrowing  of  the 
calibre  of  the  aorta  in  many  cases.  Sometimes  it  was  reduced  even 
to  a  mere  slit. 

OCCURRENCE  AND  ETIOLOGY. 

Sex. — Sex  does  not  appear  to  be  an  important  factor  in  causing 
Pott's  disease,  though  statistics  vary  somewhat. 

Age. — The  disease  is  more  common  in  childhood. 

Localization. — Any  of  the  vertebrae  may  be  attacked,  but  in  vary- 
ing frequency. 

Although  the  locations  of  relative  frequency  given  by  different 
observers  do  not  agree,  it  would  appear  that  certain  portions  of  the 


FIG.   6. — Attitude  of  Head  in  Cervical   Pott's  Disease. 

spine  are  more  liable  to  attack  than  certain  others,  and  that  the 
regions  most  liable  to  the  disease  were  those  which  were  the  most 
exposed  to  jars  or  increased  pressure;  and  that  the  disease  would 


12 


ORTHOPEDIC  SURGERY 


be  more  frequent  \vhere  the  hinges  of  motion  at  the  spinal  column 
came,  varying  to  a  degree  according  to  age  and  occupation,  or  where 
there  was  the  greatest  exposure  to  the  effects  of  violent  jars. 

Causation. — It  may  be  assumed  that  the  localizing  cause  of  Pott's 
disease  is  jar  or  superincumbent  pressure;  the  influential  cause  being 
that  physical  state  which  is  incapable  of  resisting  slight  trauma,  expos- 
ing the  tissue  probably  to  the  invasion  of  the  tubercle  bacillus. 

SYMPTOMS. 

Typical  cases  of  Pott's  disease  are  so  characteristic  in  their  symp- 
toms that  the  diagnosis  is  evident  almost  at  a  glance.  The  guarded 
character  of  all  the  movements  is  perhaps  the  most  striking  feature. 
In  walking,  in  stooping,  or  in  lying  down,  the  spine  is  most  carefully 


FIG.    /. — Attitude  in   Cervical    Caries 
of  only  Moderate  Severity. 


FIG.  8. — Attitude  Assumed  by  Children  with 
Acute  Pott's  Disease,  and  in  Other  Cases 
Necessitated  by  1'soas  Contraction. 


guarded  against  jar  and  against  motion,  attitudes  are  assumed  which 
relieve  the  vertebral  column  of  some  of  the  weight  of  the  body,  and 
:a  glance  at  the  naked  child  shows  unnatural  modes  of  standing  and 


walking. 


A  prominence  of  the  vertebrae  is  ordinarily  present  as  early  as  at 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


this  stage,  and  oftener  than  not  pain  is  acute  and  aggravated  by 
motion. 

Peculiarity  of  attitude  and  gait,  muscular  stiffness,  and  referred 
pain  are  the  most  prominent  of  the  earlier  symptoms,  and  they  may 
be  present  before  a  projection  has  been  noticed.  The  importance  of 
recognizing  these  early  symptoms  can  hardly  be  overstated,  as  it  is 
on  an  early  recognition  of  the  affection  that  the  hope  of  a  ready  cure 
is  to  be  based. 

Attitude. — These  attitudes  necessarily  vary  according  to  the  point 
of  the  spine  attacked.  In  disease  of  the  upper  cervical  region,  the 
most  common  attitude  is  that  of  wry- 
neck. 

When  the  disease  is  in  the  lower 
cervical  or  upper  dorsal  region,  the  chin 
is  held  somewhat  raised,  suggesting  the 
position  of  a  seal's  head  when  out  of 
water.  The  spinal  column  below  the 
point  of  disease  is  abnormally  straight, 
and  in  some  instances  curved  slightly 
forward,  while  in  the  lower  dorsal 
region  an  exaggerated  backward  pro- 
jection of  the  spinous  processes  may 
be  seen;  this  projection,  due  to  a  com- 
pensating curve,  is  sometimes  so 
marked  as  to  suggest  that  the  disease 
has  attacked  another  part  of  the  spine. 

In  the  middle  dorsal  region  the  atti- 
tude to  be  noticed  most  frequently  is 
an  elevation  of  the  shoulders.  Tempo- 
rarily a  slight  lateral  deviation  of  the 
spine  is  to  be  seen. 

In  the  lumbar  region,  the  patients 
in  the  early  stage  frequently  will  be 
noticed  to  lean  backward,  like  pregnant 
women  or  adults  with  large  abdomens. 
A  peculiar  position  and  characteristic 
sidling  gait,  which  is  sometimes  seen  at  a  comparatively  early  stage  of 
the  disease  in  the  lower  dorsal  or  lumbar  region,  is  due  to  a  slight 
contraction  of  the  psoas  and  iliacus  muscles.  In  a  late  stage,  when 
psoas  contraction  is  present,  a  limitation  to  the  arc  of  extension  of 
the  thigh  on  the  trunk  develops. 


I 


FIG.    9. — 


Lordosis     in     Lumbar     Pott's 
Disease. 


I4  ORTHOPEDIC  SURGERY 

In  general,  in  addition  to  the  square  position  of  the  shoulders,  the 
peculiar  position  of  the  head,  and  the  erect  attitude  of  the  upper  part 
of  the  spine,  which  prevents  the  superincumbent  weight  of  the  trunk 
and  upper  extremities  (above  the  diseased  portion  of  the  spine)  from 
falling  forward  upon  the  diseased  vertebral  body,  the  gait  is  peculiar; 
the  patient  walks  more  on  the  toes  than  on  the  heels,  and  with  the 


FIG.    10. — Attitude  Assumed  in  Dorsal   Pott's  Disease  when   Rising  from   Floor. 

knees  slightly  bent — in  such  a  way  that  all  possible  springs  may  be 
brought  into  play  to  diminish  the  jarring  of  the  spine. 

A  certain  amount  of  muscular  rigidity  of  the  muscles  of  the  back 
will  be  felt  on  palpation  in  affections  of  the  middle  dorsal  and  lumbar 
regions;  stooping  which  involves  arching  of  the  back' forward  is  diffi- 
cult or  impossible  in  disease  of  the  lower  spine,  and  in  attempting  to 
stoop  in  order  to  pick  up  any  article  from  the  floor  the  patient  will 
keep  the  spine  erect  and  reach  the  floor,  lowering  himself  with  an 
erect  trunk,  by  bending  the  knees. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


It  will  often  be  noticed  that  children  become  tired  more  easily  than 
usual,  and  after  playing  about  for  a  time  will  desire  to  lie  down,  to 
rest  their  arms  upon  a  chair  or  seat,  or  to  support  the  head  with  their 
hands,  or  the  trunk  by  holding  on  to  the  thighs,  according  to  the  part 
of  the  spine  affected. 

The  amount  of  muscular  stiffness,  rigidity,  and  difficulty  in  main- 
taining the  spine  erect  is  in  a 
measure  an  index  of  the  degree 
of  activity  of  the  disease. 

Lateral  deviation  of  the 
spine  is  an  attitude  sometimes 
to  be  found  in  Pott's  disease 
and  is  discussed  in  its  relation 
to  lateral  curvature  under  the 
head  of  diagnosis. 

Pain — In  certain  cases  of 
Pott's  disease  pain  is  absent  al- 
together, but  it  is  often  present 
to  a  distressing  degree.  The 
pain  is  rarely  complained  of  in 
the  back,  but  is  referred  to  the 
peripheral  ends  of  the  nerves, 
and  is  thus  described  as  being 
felt  in  the  abdomen,  chest,  or 
limbs.  Abdominal  pain  passes 
for  "  stomach-ache/'  and  pains 
in  the  limbs  for  "  growing 
pains "  or  rheumatism.  In 

i       -,  i          '     •  |     ,  FIG.   n. — Deformity  in  Dorsal  Pott's  Disease  Show- 

general,   it   may.be   said   here  ing  Spasm  of  Muscles, 

that  persistent  localized  pain  in 

the  case  of  a  child  is  a  symptom  demanding  very  great  attention. 
The  pain  is  usually  subacute,  and  may  be  only  occasional.  At 
times  the  attack  may  be  very  severe,  accompanied  by  intense  hyper- 
aesthesia,  so  that  the  pressure  of  the  bedclothes  cannot  be  tolerated, 
and  patients  in  this  condition  have  been  supposed  to  have  intense  peri- 
tonitis or  pleurisy.  The  subacute  form  is  more  common,  and  this, 
together  with  muscular  stiffness,  often  gives  rise  to  a  diagnosis  of 
rheumatism,  sciatica,  or  neuralgia.  Analogous  to  these  attacks  of  pain 
are  disturbances  of  the  functions  of  other  nerves — manifested  in 
cough,  peculiar  grunting  respiration,  dyspnoea  with  cyanosis,  gastric 
disorders,  obstinate  and  recurring  vomiting,  and  troubles  of  the  blad- 


i6 


ORTHOPEDIC  SURGERY 


cler,  with  or  without  pain  at  the  end  of  the  penis.  Patients  suffering 
in  this  way  have  been  treated  for  bronchitis,  pneumonia,  gastritis,  or 
cystitis. 

Deformity. — The  most  characteristic  feature  of  Pott's  disease  is 
the   deformity — that   is,   the  projection   backward   of   one   or   more 


FIG.  12. — Severe  Grade  of  Psoas  Con- 
traction. 


FIG.   13. — Lateral  Deviation  of  Spine  in 
Dorsal   Pott's   Disease.      Back  view. 


spinous  processes.  This  is  occasioned  by  the  destruction  of  the  verte- 
bral bodies.  The  projection  is  primarily  of  the  vertebrae  first  affected, 
but  following  this  other  vertebrae  are  more  or  less  involved,  and  the 
curve  increases,  with  the  establishment  of  secondary  curves.  The 
sharper  the  projection,  as  a  rule,  the  more  acute  is  the  process;  but 
this  rule,  however  true  in  the  upper  dorsal  region,  has  occasional 
exceptions  in  the  lower  dorsal  and  upper  lumbar  regions. 

It  is  most  important  to  keep  a  record  of  the  deformity  in  each 
case  under  observation.  This  record  is  most  easily  taken  by  a  simple 
method. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  17 

A  strip  of  sheet  lead  half  an  inch  wide,  of  the  quality  known  to 
the  dealers  as  "  four  pounds  to  the  foot,"  is  made  straight  by  pressing 
out  the  curves,  and  is  laid  along  the  spinous  processes  of  the  child, 
who  lies  on  his  face  on  a  flat  table  without  a  pillow,  with  his  hands 
at  his  sides  and  his  head  turned  to 
one  side.  With  the  fingers  the  lead 
is  pressed  against  the  spinous  proc- 
esses, and  when  it  is  removed  it  is 
stiff  enough  to  keep  its  shape.  The 
curve  is  then  drawn  upon  a  piece 
of  cardboard  by  means  of  this  lead 
strip,  placed  on  its  side  and  used  as 
a  ruler.  The  cardboard  curve  is  cut 
out  with  scissors  and  the  concavity 
is  then  applied  to  the  child's  back  to 
see  if  it  fits  accurately.  If  not,  it 
should  be  trimmed  with  the  scissors 
until  it  does.  The  slightest  change  in 
the  outline  of  the  back  can  then  be 
detected  at  any  subsequent  visit,  be- 
cause any  increase  or  diminution  of 
the  deformity  will  cause  the  card- 
board cutting  to  fit  the  outline  of 
the  back  imperfectly. 

If  the  deformity  is  left  to  itself, 
its  tendency  is  to  increase  until  a 
spontaneous  cure  results  or  death  en- 
sues.   In  many  cases  in  dorsal  Pott's 
disease  this  result  is   reached  only 
after  an  extensive  deformity  has  oc- 
curred.    In  cervical  and  lumbar  Pott's  disease  spontaneous  cure  is 
more  likely  to  occur,  and,  wrhen  it  occurs,  is  accompanied  by  much 
less  deformity  than  in  the  dorsal  region. 

When  this  spontaneous  cure  occurs,  the  change  takes  place  gradu- 
ally and  does  not  cause  narrowing  of  the  spinal  canal.  The  secondary 
curvatures  are :  in  cervical  Pott's  disease,  a  dorsal  incurvation  below 
the  disease,  with  a  slight  lumbar  excurvation;  in  dorsal  disease,  an 
increased  hollowing  in  above  and  below  the  gibbosity  of  the  disease;  in 
lumbar  disease,  a  long  curvature  with  convexity  inward  above  the 
disease.  The  neck  becomes  shortened  and  thickened  in  cervical  Pott's 
disease;  the  trunk  is  shortened  in  disease  of  other  parts  of  the  spine; 


FIG.  14. — Result  in  Severe  Case  of  Dorsal 
Pott's  Disease. 


i8 


ORTHOPEDIC  SURGERY 


occasionally  there  is  also  in  cases  of  long  duration  a  diminution  in 
the  growth  of  the  whole  body,  so  that  adults  recovered  from  Pott's 
disease  of  ordinary  severity  are  of  less  than  average  height.  An 
alteration  in  the  shape  of  the  lower  part  of  the  face  takes  place  in 
marked  dorsal  disease,  with  a  facial  expression  which  is  characteristic. 
Cases  in  which  the  deformity  is  rapidly  increasing  are,  as  a  rule, 
characterized  by  much  pain. 

Deformity  of  the  chest  is  a  constant  accompaniment  of  dorsal 
Pott's  disease.     The  vertebral  column  cannot  give  way  and  form  an 


FIG.   15. — Method   of  Measurement  of  Deformity  in   Pott's   Disease.      Shows   lead   strip  and   card- 
board tracing.      (Children's  Hospital   Report.) 

angular  deformity  without  altering  the  position  of  the  sternum  and 
ribs.  The  deformity  is  usually  a  thrusting  downward  and  forward 
of  the  sternum  with  a  lateral  flattening  of  the  chest.  In  short,  it 
results  in  the  formation  of  a  pigeon-breast.  There  may,  however,  be 
a  prominence  of  the  ribs  on  both  sides  of  the  sternum,  where  a 
depression  of  the  sternum  is  seen.  Sometimes  the  pigeon-breast  is 
the  first  symptom  to  attract  the  attention  of  the  parents,  and  for  that 
alone  the  children  are  brought  to  the  surgeon. 

High  Temperature. — Cases  with  Pott's  disease  not  infrequently 
have  an  elevation  of  the  temperature  in  the  afternoon.  This  tem- 
perature is  diminished  or  often  reduced  to  normal  in  cases  under  bed 
treatment.  The  rise  of  temperature  is  from  one  to  three  degrees  in 
average  cases  and  occurs  independently  of  abscesses. 

COMPLICATIONS. 

Paralysis. — Partial  or  complete  paralysis  of  the  legs  is  a  frequent 
complication  of  Pott's  disease.  It  may  occur  in  early  or  late,  in  mild 


TUBERCULOUS  DISEASE  OF  THE  SPINE  19 

or  severe  cases,  and  frequently  no  apparent  exciting  cause  can  be 
assigned  for  its  appearance.  The  motor  paralysis  varies  from  mere 
muscular  weakness  to  complete  loss  of  power.  It  begins  as  a  sense 
of  fatigue,  a  dragging  of  the  feet;  then  there  is  inability  to  hold  one's 
self  erect.  Unless  the 
disease  is  in  the  lumbar 
region,  the  reflexes  are 
exaggerated,  and  muscu- 
lar spasms  may  start  from 
the  least  irritation;  they 
frequently  appear  spon- 
taneously. In  severe 
cases  the  muscles  are  flac- 
cid and  the  legs  may  be 
powerless.  With  the  sec- 
ondary degenerations  in 
the  cord,  rigidity  sets  in. 
The  bladder  and  rectum 
are  paralyzed  toward  the 
end  of  all  severe  cases  of 
paralysis,  and  whenever 
the  lumbar  enlargement  is 
involved;  in  milder  cases 
they  escape.  The  arms 
are  paralyzed  in  excep- 
tional instances  of  dorsal 
Pott's  disease.  Of  the 
sensory  paralysis  below 
the  lesion  there  is  less  to 
be  said;  it  is  apt  to  begin 
as  paraesthesia ;  anaes- 
thesia afterward  may  come  on  to  a  greater  or  less  extent.  Trophic 
disturbances  are  not  to  be  seen  unless  in  exceptional  cases. 

The  wasting  of  the  muscles  and  diminution  of  electric  contractility 
are  usually  only  such  as  disuse  would  cause. 

In  a  few  instances  affections  of  the  joints,  supposed  to  be  second- 
ary to  lesions  of  the  cord,  have  been  noted,  and  instances  are  men- 
tioned in  which  herpes  zoster,  apparently  due  to  the  same  cause,  was 
present. 

Paralysis  is  rarely  an  early  symptom  in  Pott's  disease,  though  it 
has  been  observed  before  the  stage  of  deformity.  The  frequency  of 


FIG.  16.— Deformity  from  Disease  in  the 
Dorsal  Region. 


20 


ORTHOPEDIC  SURGERY 


paralysis  is  indicated  by  the  figures  collected  in  700  cases  observed 
by  Dollinger.  Forty-one  cases  of  paralysis  were  noted  (5.8  per  cent). 
In  26  of  the  41  cases  the  disease  involved  the  region  from  the  third 
to  the  seventh  dorsal  vertebrae  inclusive. 

Paralysis  is  usually  bilateral;  it  may,  however,  be  unilateral,  and 
in  some  unusual  instances  it  occurs  above  the  point  of  deformity. 
Taylor  and  Lovett  1  found,  in  an  examination  of  59  cases  of  paralysis 
(out  of  445  cases  of  Pott's  disease),  that  the  location  of  the  disease 
was  as  follows:  i  cervical,  7  cervico-dorsal,  37  dorsal,  7  dorso- 
lumbar,  4  lumbar,  3  unclassified.  The  deformity  was  large  in  20, 
medium  in  10,  small  in  17  (in  12  unclassified).  The  paralyzed  cases 
presented  no  worse  deformity  than  that  seen  in  average  cases.  In 
26  the  outline  of  the  deformity  was  rounded  and  gradual;  in  16  it 
was  distinctly  sharp.  The  paralysis  occurred  on  the  average  about 
two  years  after  the  beginning  of  the  disease.  It  came  on  immediately 
after  a  fall  in  4  cases.  The  duration  of  the  paralysis  was  never,  in 
the  cases  reported,  over  three  years,  except  in  one  case,  when  it  per- 
sisted with  but  little  improvement  for  six  years;  in  2  cases  it  lasted 
three  years;  in  5  cases  it  lasted  two  years.  A  recurrence  of  the 
paralysis  was  noted  in  6  cases,  4  having  two  attacks  and  2  having 
three. 

Paralysis  is  not  a  common  occurrence  in  Pott's  disease  under  effi- 
cient protective  treatment.  Its  prognosis  is  extremely  favorable  in 

mild  cases,  or  in  severe  ones  if  they 
can  be  treated  early.  Recovery, 
when  it  occurs,  is  generally  complete, 
leaving  no  trace  of  the  disability  of 
the  limbs. 

Abscess. — In  most  cases  of 
Pott's  disease,  especially  in  those 
under  efficient  treatment,  the  whole 
course  is  run  without  any  evi- 
dence of  suppuration  other  than 
that  afforded  by  the  -i'-ray, 
where  a  shadow  around  the  dis- 
eased area  apparently  indicating 
pus  is  common,  but  in  others 
abscesses  form  a  distressing  complication. 

The  earlier  treatment  is  begun  and  the  more  efficiently  it  is  carried 
out,  the  less  liable  are  abscesses  to  form ;  but  it  must  not  be  assumed 

.  Rec.,  1886,  xxix.,  699. 


FIG.    17. — Diagram   of   Abscess   from   Pott's 
Disease. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


21 


that  the  occurrence  of  abscesses  is  evidence  of  incomplete  treatment. 
In  certain  cases  of  severe  disease  an  abscess  cannot  be  avoided. 

The  causes  of  development  of  an  abscess  are  the  same  in  Pott's 
disease  as  in  bone  tuberculosis  elsewhere.  And  the  most  common  form 
is  psoas  abscess,  so-called  from  its  localization  in  the  region  of  the 
insertion  of  the  psoas  muscle. 


FIG.   1 8. — Examination  for  Psoas  Contraction.      (Children's  Hospital   Report) 

Abscesses  may  accumulate  in  the  inguinal  region  above  Pcupart's 
ligament,  simulating  hernia.  Before  passing  down  the  sheath  of  the 
psoas  muscle,  they  may  enlarge  in  the  abdominal  cavity  beneath  the 
peritoneum,  constituting  a  layer  of  subperitoneal  abscesses.  In  time 
these  abscesses  descend  down  the  thigh,  but  they  may  remain  for  a 
long  time  large,  threatening,  abdominal  tumors. 

A  lumbar  abscess  appears  as  a  swelling  in  the  loin  on  one  side  or 
the  other  just  outside  the  quadratus  lumbornm. 

Abscess  in  dorsal  disease  may  pass  between  the  ribs  and  appear 


FIG.    19. — Psoas  Abscess. 

as  a  tumor  on  one  side  of  the  spine,  or  the  accumulation  of  pus  may 
remain  in  the  posterior  mediastinum,  giving  rise  to  cough  and 
dyspnoea,  and  may  be  detected  as  an  area  on  one  side  of  the  spine, 
dull  to  percussion. 

Cervical  abscess  appears  as  a  tumor  at  the  side  of  the  neck,  simu- 
lating the  ordinary  deep  cervical  abscess,  or  it  may  appear  as  a  bunch 


22 


ORTHOPEDIC  SURGERY 


at  the  back  of  the  pharynx,  causing  difficulty  in  breathing  and  swal- 
lowing.    The  latter  is  known  as  a  retropharyngeal  abscess. 

Abscesses  may  exceptionally  burst 
into  the  mouth,  trachea,  bronchi, 
mediastinum,  oesophagus,  or  pleura. 
They  may  rupture  into  the  intes- 
tines, bladder,  vagina,  rectum,  or 
the  abdominal  cavity;  and  one  case 
is  reported  in  which  spinal  abscess 
simulated  a  fistula  in  ano.  Ab- 
scesses may  also  burst  into  the  spinal 
canal  or  the  hip- joint.  Occasionally  they 
burst  in  the  alimentary  canal,  not 
so  rarely  in  the  lungs,  and  excep- 
tionally in  the  peritoneum  or  larger 
vessels. 

Abscesses  in  the  lung  give  rise 
to  less  disturbance  than  would  be 
supposed;  in  reality  they  present  the 
rational  and  physical  signs  of  a  low 
form  of  localized  pneumonia,  of  a 
chronic  or  subacute  type. 

An  abscess  may  remain  stationary 
in  size  and  quiescent  for  a  long 
time — a  condition  which  may  be  com- 
patible with  fair  general  health.  In- 
stances are  not  uncommon  in  which 
adults  have  been  able  to  attend  to 
active  work  and  children  to  play 
about,  although  suffering  from  large 
cold  abscesses. 

When   absorption   takes  place   the 
fluid  contents  disappear,  and  the  case- 
ous and  purulent  detritus,  if  present,  in  all  probability  becomes  encap- 
sulated.   This  frequently  happens  even  in  large  psoas  abscesses. 


FIG.    20. — Lumbar   Abscess. 


DIAGNOSIS. 

The  diagnosis  is  based  on  physical  signs : 

These  are : 

i.  Stiffness  of  the  spine  in  walking  and  in  passive  manipulation. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  23 

2.  Peculiarity  of  gait  and  attitudes  assumed,   according  to  the 
location  of  the  disease. 

3.  Lateral  deviation  of  the  spine. 

For  all  examinations  children  should  be  stripped. 


FIG.  21. — Cervical  Abscess. 

i.  Muscular  Stiffness. — On  examining  for  muscular  stiffness  of 
the  spine,  the  child  is  most  conveniently  laid  face  downward  on  a 
table  or  bed,  and  lifted  by  the  feet.  In  a  normal  back  the  lumbar 
and  lower  dorsal  spine  can  be  markedly  bent,  and  a  general  mobility 
of  the  whole  column  is  seen.  In  patients  in  whom  Pott's  disease  is 


24  ORTHOPEDIC  SURGERY 

present  the  region  affected  is  held  rigidly  by  muscular  contraction 
when  manipulation  is  attempted.  Lifting  the  patient  by  the  feet  in 
this  way  will  show  the  existence  of  lumbar  or  lower  dorsal  rigidity, 


FIG.   22. — On   Left   Scoliosis.       On   Right   Old  Dorsal  Pott's  Disease. 

but  it  does  not  detect  high  dorsal  Pott's  disease.  In  lumbar  Pott's 
disease  lateral  mobility  of  the  spine,  as  well  as  antero-posterior 
flexibility,  is  lost. 

2.  Peculiar  Gait  and  Attitudes. — In  general  the  walk  is  careful, 
and  steps  are  taken  with  such  care  that  jars  to  the  spine  are  avoided. 

CERVICAL  POTT'S  DISEASE. — The  most  common  symptom  of  the 


TUBERCULOUS  DISEASE  OF  THE  SPINE  25 

disease  in  this  region  is  the  occurrence  of  wry-neck  with  stiffness 
of  the  muscles  of  the  back  and  neck. 

In  disease  of  the  upper  cervical  vertebra  the  head,  however,  may 
be  held  sharply  flexed  and  sunk  upon  the  chest.  It  may  be  hyperex- 
tended  with  the  occiput  resting  on  the  upper  part  of  the  spine,  or  it 
may  be  held  laterally  bent. 

UPPER  DORSAL  POTT'S  DISEASE. — In  this  region  detection  of  the 
disease  is  less  difficult,  because  bony  destruction  at  once  results  in 


FIG.    23. — Rigidity    of    Spine    in    Pott's    Disease.    (Children's    Hospital    Report.) 

angular  deformity,  on  account  of  the  posterior  curve  of  the  spine  in 
this  part. 

The  shoulders  are,  however,  held  high  and  squarely,  the  gait  is 
careful.  In  Pott's  disease,  paralysis  may  exceptionally  be  the  first 
perceptible  symptom. 

LUMBAR  POTT'S  DISEASE. — Vertebral  disease  in  this  region  of 
the  spine  is  sometimes  difficult  of  detection  at  an  early  stage,  as  a 
knuckle  is  not  developed  in  as  early  a  stage  as  in  other  parts  of  the 
spinal  column,  but  stiffness  in  gait  and  peculiarity  of  attitude  are 
characteristic.  The  attitude  is  that  of  lordosis,  which  in  some  cases 
becomes  very  marked;  the  gait  is  military  and  careful. 

3.  Lateral  Deviation  of  the  Spine. — During  the  acute  stage  of  the 
disease  a  leaning  of  the  spine  to  one  side  is  often  noted.  In  this  con- 


26 


ORTHOPEDIC  SURGERY 


dition  the  spinous  processes  do  not  form  the  arc  of  a  circle  as  in 
scoliosis,  but  the  lateral  curve  is  more  a  side  bend  at  the  site  of  the 
disease  and  rotation  is  absent.  It  is  generally  due  to  acute  muscular 
irritability  and  disappears  with  recumbency,  when  it  occurs  later  on 
in  the  course  of  the  disease  it  is  due  to  unilateral  destruction  of  the 
bodies.  (See  Fig.  5.) 

Skiagrams  of  the  spine  are  of  assistance  in  the  diagnosis,  especially 
if  taken  from  the  side  showing  the  spine  in  contour.    In  such  cases  early 


FIG.    24. — Normal    Flexibility    of    Spine.        (Children's   Hospital    Report.) 

changes  may  be  seen,  showing  destruction  of  part  of  one  or  bodies. 
When  taken  from  the  front  a  skiagram  shows  first  a  disappearance 
of  the  intervertebral  space  between  two  bodies  and  then  a  destruction 
of  vertebral  bodies  shown  by  loss  of  contour  and  crowding  together. 
A  shadow  indicating  abscess  is  frequently  seen. 

Lumbar  Pott's  disease  is  occasionally  mistaken  for  single  or  double 
hip  disease,  or  is  regarded  as  a  rhachitic  curvature. 

\Yhen  the  hip  symptoms  are  due  to  Pott's  disease  and  are  caused 
by  psoas  irritability,  the  restriction  of  motion  in  the  hip  is  simply  in 


TUBERCULOUS  DISEASE  OF  THE  SPINE  27 

the  loss  of  hyperextension,  while  abduction  and  internal  rotation  are 
free  and  net  affected.  This  limitation  of  motion  in  only  one  direction 
is  generally  sufficient,  in  connection  with  the  other  symptoms,  to  estat> 


FIG.  25.— Antero-posterior  X-Ray  of  Tubercular  Spine,  showing  Fusion  of  Diseased  Vertebrae  and 
Disappearance  of  Intervetebral  Discs. 

lish  the  presence  of  Pott's  disease.  On  the  other  hand,  in  some  cases 
the  limitation  of  the  hip's  motion  is  in  all  directions,  and  simulates 
very  closely  the  limitation  of  true  hip  disease. 

DIFFERENTIAL   DIAGNOSIS 

Rhachitic  deformity  of  the  spine  is  a  posterior  curvature,  is  usually, 
though  not  always,  rounded  and  not  angular.  It  is  less  sharp  and  there 
is  less  muscular  stiffness  than  in  Pott's  disease.  It  occurs  at  the  junc- 
tion of  the  dorsal  and  the  lumbar  regions.  This  junction  is  also  a 
frequent  site  of  Pott's  disease. 

Hyperaesthetic  spine  is  characterized  by  tenderness  in  certain  por- 
tions of  the  back,  sometimes  accompanied  by  pain  or  ache.  This  con- 
dition is  more  common  in  neurotic  persons,  but  may  be  seen  in  others 


28 


ORTHOPEDIC  SURGERY 


who    have    been    suffering    from    nervous    exhaustion     from    any 
cause.     As   a    rule,    no    real    stiffness    in    the   back    is    present,    but 

in  severe  cases,  or  in  cases  which 
may  have  remained  in  bed  for 
some  time,  muscular  stiffness  may 
be  present. 

Malignant  disease  of  the  spine 
presents,  when  a  projection  is 
found,  a  more  rounded  ajnd  less 
sharp  projection  than  is  seen  in  the 
beginning  of  caries.  Carcinoma  of 
the  spine  is  usually  secondary. 
The  symptoms,  however — pseudo- 
neuralgias,  paresis,  paralysis,  and 
muscular  stiffness — are  the  same 
in  both,  and  sometimes  cnly  a  con- 
jectural diagnosis  can  bei  made. 
Sarcoma  of  the  spine  is  a  rare  af- 
fection in  childhood. 

In    curvatures     of     the"     spine 
caused  by  aneurism,  the  diagnosis 
is  usually  made  by  auscult4tion  or 
by  the  rational  symptoms  before  the  spine  is  noticeably  affected. 

Tumors  pressing  on  the  spinal  cord  may  cause  -stiffness  of  the 
back  and  pain  referred  to  the  peripheral  ends  of  the  nerves.  Angular 
deformity,  however,  is  absent,  and  the  symptoms  of  nervous  disturb- 
ance predominate  over  the  ordinary  ones  of  Pott's  disease. 

Acute  Osteomyelitis  of  the  spine  may  be  secondary  or  primary. 
The  transverse  and  articular  processes  as  well  as  the  vertebral 
bodies  may  be  affected,  and  tenderness  is  present  at  the  seat 
of  disease.  Suppuration  elsewhere  occurs  in  sixty  per  cent  of 
all  cases.  There  is  much  constitutional  disturbance,  fever  is  high, 
and  the  course  rapid.  CEdema  of  the  affected  parts  appears  early; 
abscesses  of  a  very  acute  and  extensive  character  as  well  as  paralysis 
are  other  early  features.  The  formation  of  a  kyphus  of  any  extent 
is  unusual. 

A  subacute  or  chronic  form  of  vertebral  osteomyelitis  is  met  with 
more  often  secondary  to  a  germ  infection.  This  has  been  termed 
"  typhoid  "  spine  and  may  resemble  Pott's  disease.  The  affection  is 
more  rapid  than  the  tuberculous  process.  It  is  less  common  in 
children. 


FIG.  .?6.  -  Lateral  X-Kay  of  Tubercular  Spine, 
showing  Collapsing  of  Two  Diseased 
Vertebrae. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  29 

Spondylitis  deformans  of  the  spine  is  an  affection  most  frequent 
in  adult  life,  characterized  on  superficial  examination  by  stiffness  and 
some  arching  of  the  spine;  in  some  instances  the  ribs  are  ankylosed 
to  the  spine,  so  that  no  expansion  of  the  chest  is  possible.  Stiffness 
of  the  back  is  present,  but  the  whole  spine  is  rigid  and  other  joints 
may  be  involved.  These  cases  may  occur  in  connection  with  gonor- 
rhoea. 

From  round  shoulders,  Pott's  disease  is  generally  to  be  distin- 
guished by  the  fact  that  in  the  former  the  spine  is  flexible  and  the 
deformity  rounded  and  not  angular.  The  distinction  is  generally 
easily  made. 

Spondylolisthesis,  or  dislocation  forward  of  one  of  the  lumbar 
vertebne,  may  cause  pain,  Icrdosis,  and  peculiarity  of  gait  and 
posture. 

With  regard  to  the  symptoms  of  sacro-iliac  disease,  pcrinephritis, 
and  appendicitis,  it  may  be  said  that  a  mistake  in  diagnosis  may  hap- 
pen, but  that  ordinarily  there  is  no  obscurity.  It  should,  however,  be 
borne  in  mind  that  in  appendicitis  and  in  perinephritis,  when  an 
abscess  is  present,  a  contraction  of  the  thigh  may  occur,  resembling 
that  seen  in  psoas  abscess.  The  absence  of  a  projection  or  irregularity 
of  the  back,  and  the  power  of  muscular  movement  of  the  back  in  these 
cases,  will  help  to  establish  the  fact  that  they  are  not  due  to  disease 
of  the  spine. 

Skiagrams  in  early  cases  of  Pott's  disease  sometimes  aid  in  the 
diagnosis,  but  are  often  negative. 

PROGNOSIS. 

Pott's  disease  will  always  be  regarded  as  one  of  the  most  formi- 
dable of  diseases ;  its  long  course,  the  deformity  entailed,  the  severity 
of  the  complications,  and  the  occasional  termination  in  death  give 
both  to  the  surgeon  and  to  the  non-professional  public  a  natural  dread 
of  the  affection.  These  inferences  are,  however,  drawn  from  the 
severer  cases,  and  facts  show  that  the  disease  has  a  tendency  to  re- 
covery, that  the  deformity  can  be  prevented,  and  that  in  few  affections 
does  the  work  of  the  surgeon  give  greater  benefit  than  in  Pott's 
disease. 

Mortality. — No  statistics  of  value  exist  as  to  the  percentage  of 
mortality  and  recovery. 

The  tendency  of  the  deformity  is  to  increase,  during  the  years  of 
growth,  and  this  is  specially  marked  in  the  upper  dorsal^  region. 
Instances  of  arrest  without  great  deformity  are  not  rare  in  upper 


30  ORTHOPEDIC  SURGERY 

cervical  disease  and  in  lumbar  disease,  but  in  the  upper  and  middle 
dorsal  regions  the  tendency  is  for  an  increase  of  the  deformity  pro- 
portionate to  the  extent  of  the  disease. 

The  disease  varies  greatly  as  to  its  self-limitation  in  individuals, 
and  according  to  the  situation  and  extent  of  the  disease.  Neces- 
sarily there  will  be  a  difference  in  individual  cases  in  the  result  of 
treatment. 

It  may  be  said  that,  as  the  bodies  in  the  cervical  region  are  smaller 
than  those  in  the  lumbar,  the  time  required  for  self-limitation  here 
is  shorter  than  in  the  lumbar  region.  In  the  latter  region,  also,  the 
superincumbent  weight  is  a  more  important  factor  than  in  the  upper 
part  of  the  spine. 

The  occurrence  of  bony  formation  firm  enough  to  support  the 
column  in  its  weight-bearing  function  must  be  a  process  requiring  a 
long  time  for  its  completion,  to  judge  from  it  as  observed  elsewhere; 
and  nowhere  is  protection  more  urgently  demanded  during  con- 
valescence than  in  the  vertebral  column.  This  is  especially  true  in 
growing  children.  Cases  of  supposed  cure  of  Pott's  disease  have 
redeveloped  symptoms  at  the  period  of  rapid  growth  at  the  approach 
of  puberty.  It  should  especially  be  borne  in  mind  that  protection  to 
the  spine  may  be  needed  at  this  period. 

TREATMENT. 

This  varies  according  to  the  stage  and  condition  of  the  patholog- 
ical process. 

Treatment,  therefore,  is  different  in  the  acute,  the  subacute,  and 
the  convalescent  stages.  In  the  acute  stage  recumbency  is  the  most 
efficient  method  and  from  a  mechanical  point  of  vie\v  the  most  sound. 
In  the  subacute  and  convalescent  stage  ambulatory  treatment  with 
more  or  less  efficient  spinal  protection  is  advisable. 

TREATMENT  BY  RECUMBENCY. 

If  the  patient  lies  upon  his  back  or  upon  his  face  on  a  hard  surface, 
there  is  no  superincumbent  weight  pressing  upon  any  portion  of  the 
spine.  If  the  patient  lies  upon  his  back  upon  a  spring-bed,  and  the 
bed  sags,  the  spine  is  of  course  bent,  and  pressure  upon  the  vertebra?, 
proportional  in  amount  to  the  extent  of  the  curve,  results. 

If  treatment  by  recumbency  is  to  be  adopted,  it  is  not  sufficient 
simply  to  place  the  child  in  bed.  Sagging  of  the  mattress,  moving  of 
the  patient  from  side  to  side,  twisting  and  turning  are  all  injurious, 


TUBERCULOUS  DISEASE  OF  THE  SPINE  31 

in  that  they  cause  motion  between  the  vertebrae  and  change  inter- 
articular  pressure,  both  of  which  are  undesirable. 

It  is  necessary  that  the  child  should  be  fixed  in  a  suitable  position 
in  bed.  This  can  be  done  by  securing  the  child  in  such  a  manner  that 
the  vertebral  column  at  the  seat  of  the  disease  is  arched  forward, 


FIG.  27. — Gas-Pipe  Frame. 

diminishing  the  interarticular  pressure.  The  simplest  way  of  doing 
this  is  by  means  of  a  frame. 

The  rectangular  bed  frame  consists  of  a  stretcher  of  heavy  cloth 
attached  to  a  rectangular  gas-pipe  frame.  The  child  lying  upon  this 
frame  can  be  secured  by  means  of  straps  across  the  shoulders  and 
pelvis  and  knees,  and  can  be  carried  about  without  jar.  When  the 
frame  is  placed  upon  the  bed,  the  cloth  covering  is  no  more  uncom- 
fortable than  the  surface  of  the  bed. 

But  simple  recumbency  alone  is  not  sufficient  to  promote  cicatricial 
ostitis.  The  removal  of  intervertebral  pressure  is  also  necessary. 
This  is  to  be  accomplished  by  arching  the  spinal  column  forward  at 


FIG.   28. — Method   of   Securing  Child  to   Bed   Frame   for   Recumbent   Treatment   of  Dorsal   Pott's 

Disease. 

the  point  of  the  kyphotic  curve,  by  placing  under  the  curve  of  the 
child  lying  upon  the  back  a  firm  pad,  pressing  upon  each  side  of  the 
spinous  process,  and  sufficiently  high  to  press  this  part  upward  while 
the  rest  of  the  spinal  column  drops  back  by  its  own  weight.  The 


32  ORTHOPEDIC  SURGERY 

pads  can  be  furnished  by  properly  folded  sheets  or  towels,  by  a  bag  of 
fine  sawdust,  by  felt  padding,  or  by  a  plaster-of-Paris  back 
moulded  to  a  corrected  position  of  the  spine,  or  by  arching  the  frame, 
as  has  been  suggested  by  Silva,  Hunkin,  and  Whitman.  If  the  frame 
is  made  narrow  the  child's  outer  clothing  can  be  placed  around  the 
frame  and  child,  which  is  an  advantage  in  carrying  the  child  about. 
This  holds  the  spine  hyperextended  throughout  its  length. 

In  cervical  caries  head  traction  in  a  recumbent  position  will  be 
found  of  use  in  cases  of  torticollis;  and  in  severe  neuralgia  from  cervi- 


ne.   29. — Traction  in  Cervical  Caries.      (Children's  Hospital   Report.) 

cal  caries  the  relief  afforded  is  often  very  marked.  Traction  can  be 
furnished  by  means  of  a  head  sling  passing  over  the  forehead  and 
occiput,  which  is  attached  to  a  weight  and  pulley  running  over  the  head 
of  the  bed  or  to  the  head  of  the  frame.  The  counter  pull  may  be  fur- 
nished by  the  weight  of  the  body  in  case  the  head  of  the  bed  is  raised, 
by  a  downward  pull  upon  the  trunk  through  a  waist  band,  or  by  means 
of  traction  applied  to  the  limbs. 

Treatment  by  recumbency,  if  used,  should  be  thorough.  The 
objections  to  treatment  by  recumbency  are  evident.  Pott's  disease  is 
a  tuberculous  affection  and  patients  of  this  sort  need  all  possible  help 
from  fresh  air,  but  in  these  days  patients  may  be  recumbent  out  of 
doors.  Recumbency  is  necessarily  the  most  efficient  treatment  me- 


TUBERCULOUS  DISEASE  OF  THE  SPINE  33 

chanically  and  in  France  is  pursued  through  the  acute  disease  with 
admirable  results.  But  the  hospital  class  in  America  will  not,  as  a  rule, 
carry  it  out  and  ambulatory  measures  must  generally  be  adopted  in 
routine  cases. 

AMBULATORY  TREATMENT. 

Treatment  by  Plaster  Jackets. — The  purpose  of  the  treatment  by 
plaster  jackets  is  to  fix  the  spine  so  firmly  that  there  will  be  no  injury 

to  the  affected  vertebrae  from  the 
jar  incident  to  locomotion. 

Plaster  jackets  are  made  by 
applying  successive  layers  of  prop- 
erly prepared  bandages  to  the  pa- 
tient's trunk,  which  has  been 
placed  in  a  suitable  position. 

The  patient  during  the  appli- 
cation of  a  plaster  jacket  is  either 
upright  or  recumbent  (on  back  or 
face),  with  or  without  a  suspen- 
sion or  a  traction  pull. 

APPLICATION  OF  JACKET 
WITH  THE  PATIENT  SUSPENDED. 
— Suspending  a  healthy  person  by 
the  head  diminishes  the  physio- 
logical curves  (cervical  and  lum- 
bar lordosis,  dorsal  kyphosis), 
and  the  spine  becomes  straight  so 
far  as  its  formation  will  allow. 

The  patient's  clothes  are  re- 
moved and  a  thin,  tightly  fitting 
undershirt  is  applied,  put  on  so 
as  to  present  no  wrinkles.  The 
patient  is  thickly  padded  by  felt 
or  sheet-wadding  pads  over  the 
pelvis  and  two  thick  felt  pads  are 

placed  longitudinally  at  the  sides  of  the  kyphus.  The  patient  is  then 
suspended ;  the  head  is  secured  in  a  sling,  which  is  attached  to  a  strong 
cord  playing  in  a  pulley,  or  series  of  pulleys,  fastened  to  a  point  above 
the  patient's  head.  An  assistant  pulling  on  the  cord  raises  the  patient 
so  that  the  heels  are  free  from  the  floor.  It  is  desirable  to  diminish 
the  strain  upon  the  neck,  and  padded  loops  connected  with  the  bar, 


FIG.   30. — "Sayre  Headpiece  for  Suspension  in 
Pott's   Disease. 


34  ORTHOPEDIC  SURGERY 

which  is  raised  by  the  cord  and  pulley,  can  be  passed  under  each  axilla, 
or  handles  may  be  held  in  each  hand,  connected  with  cords  which  play 
over  pulleys. 

The  bandages  are  then  wound  smoothly  around  the  patient.  If 
the  plaster  is  fresh  and  of  the  best  quality,  it  should  harden  in  five 
minutes.  After  the  plaster  is  hard  or  nearly  hard,  the  patient  is  to 
be  placed  on  a  soft  flat  surface,  care  being  taken  not  to  crack  the 
plaster  in  so  doing.  The  edges  of  the  jacket  are  smoothed  down  and 
cut  off  if  they  press  uncomfortably  on  the  thighs  or  axilla?. 

It  is  important  that  the  jacket  should  be  strong  in  front  as  well  as 
behind,  and  should  be  wound  as  high  as  possible  in  front,  in  order  to 
prevent  the  spinal  column  from  falling  forward.  If  the  jacket 
becomes  broken  or  softened,  it  should  be  removed  and  another  applied. 

If  the  disease  is  in  the  cervical,  or  upper  dorsal  region,  the 
plaster  bandages  should  be  carried  up  around  the  back  of  the  head 
and  neck  and  under  the  chin,  leaving  the  face  and  upper  part  of  the 
head  exposed,  and  so  fixation  and  support  may  be  obtained  in  that  part 
of  the  vertebral  column. 

CALOT'S  METHOD. — The  modified  method  of  Calot  consists  in 
the  application  of  a  highly  efficient  plaster  jacket,  followed  by 
recumbency  in  a  corrective  jacket  for  a  period  of  two  years.  The 
jacket  is  applied  in  strong  suspension  by  means  of  sheets  of  crinoline 
impregnated  with  plaster  cream,  which  are  secured  in  place  by 
ordinary  plaster  bandages  wound  outside.  In  all  cases  the 
shoulders  are  included  in  the  jacket,  which  terminates  above 
in  a  "  military  collar."  In  the  upper  dorsal  region  a  plas- 
ter headpiece  is  used.  A  square  window  is  cut  over  the  kyphus 
and  layers  of  absorbent  wool  are  placed  between  the  square  of  plaster 
removed  and  the  back.  This  square  of  plaster  is  then  fastened  in  place 
by  bandages  making  compression  on  the  kyphus.  The  -number  of 
layers  is  subsequently  increased  to  keep  up  an  increasing  corrective 
pressure  at  the  same  time  a  larger  window,  triangular  in  shape  with 
the  apex  upward,  is  removed  from  the  front  of  the  jacket  to  allow 
the  spine  to  be  pushed  forward  at  the  level  of  the  kyphus.  The  details 
of  the  method  are  given  in  the  reference.1 

APPLICATION*  DURING  RECUMBENCY  ON  THE  FACE. — The  patient 
is  laid  face  downward  with  the  arms  above  the  head  on  a  hammock, 
which  consists  of  a  stout  cloth  a  little  wider  than  the  child,  stretched 
over  the  ends  of  a  rectangular  gas-pipe  frame.  One  end  of  this  cloth 
is  attached  to  the  upper  end  of  the  frame  and  does  not  move.  The 

1  F.  Calot:  "  L' Orthopedic  Indispensable,"  Paris,  1909,  p.  7. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


35 


other  end  it  attached  to  a  movable  bar  connected  with  the  other  end 
of  the  frame  by  a  rope.  By  a  ratchet  this  bar  can  be  pulled  upon  and 
the  tension  of  the  cloth  regulated.  The  hammock  may  be  made  very 
tight  or  allowed  to  sag  to  any  extent.  In  this  way  hyperextensicn  of 
the  spine  may  be  produced  as  desired. 

The  hammock  cloth  is  cut  along  the  sides  of  the  child's  body 


FIG.  31. — Frame  for  Applying  Jacket  with  Patient  Recumbent  upon  the  Back.      (Metzger- 

Goldthwait.) 

longitudinally  and  the  parts  not  under  the  child's  body  are  drawn  aside 
and  fastened  or  cut  away.  The  plaster  rollers  are  then  applied,  includ- 
ing both  child  and  hammock. 

Instead  of  the  stretched  hammock  cloth,  the  patient  may  be  placed 
on  two  pieces  of  stout  webbing  stretched  along  the  length  of  a  rectan- 
gular frame.  These  should  be  placed  sufficiently  near  together  to 
support  the  trunk  without  pressure  upon  the  chest.  Cross  straps  of 
webbing  are  necessary  at  the  hips  and  shoulders  when  the  jacket  is 
applied.  The  webbing  straps  are  untied  and  patient  released,  after 
which  they  are  pulled  out. 

APPLICATION  OF  A  JACKET  WITH  THE  PATIENT  PLACED  UPON 
THE  BACK. — In  applying  a  jacket  with  the  patient  lying  upon  the 
face  some  compression  of  the  chest  and  Flattening  of  the  abdomen 
take  place.  To  avoid  this,  a  jacket  can  be  applied  with  the  patient 
placed  upon  his  back.  If  this  were  done  with  the  patient  lying  upon 
a  stretched  sheet,  the  sagging  of  the  material  would  prevent  the 
necessary  hyperextension  of  the  spine. 

An  upright  steel  rod  is  arranged  with  a  forked  top  on  which  can 
be  placed  two  attachable  pad  plates.  The  rod  fits  in  a  stand  and  can 
be  raised  or  lowered  by  means  of  a  screw.  If  the  patient  is  made  to 
lie  in  such  a  way  that,  while  the  head,  shoulders,  and  pelvis  are  sup- 
ported the  kyphus  rests  upon  the  pad  plates,  a  hyperextending  force 
is  exerted  on  the  kyphus.  As  the  rod  bearing  the  pad  plates  is  raised 


36  ORTHOPEDIC  SURGERY 

or  lowered,  the  pressure  on  the  kyphus  is  increased  or  diminished. 
Any  desired  amount  of  hyperextension  of  the  spine  can  be  furnished. 

Exaggerated  lordosis  can  be  prevented  by  flexing  the  thighs. 

JACKETS  APPLIED  WITH  THE  PATIENT  SITTING. — The  patient 
may  be  seated  during  the  application  of  the  jacket  if  it  is  desired  t3 
prevent  lordosis  in  the  lumbar  region. 

In  disease  of  the  lumbar  region,  since  lordosis  is  desirable  to 
separate  the  lumbar  vertebne,  suspension  is  not  necessary.  The  jacket 
can  be  applied  with  the  patient  steadied  and  the  back  arched  forward 
to  secure  exaggerated  lordosis. 

It  is  desirable  that  the  surgeon  should  familiarize  himself  with 
the  application  of  plaster  jackets  by  the  different  methods  mentioned, 
as  it  will  be  found  that  thev  are  of  assistance  in  different  cases. 


FIG.  32.— Posterior  Shell  for  Recumbent  Treatment  of  Tubercular  Spine. 

The  most  acceptable  form  of  permanent  jacket  is  one  applied  over 
a  seamless  woven  shirt.  These  shirts  are  made  very  long  and  reach 
the  knees;  one  of  them  is  put  en  the  patient  and  the  jacket  applied 
over  it.  The  lower  part  of  the  shirt  is  then  turned  up  over  the  outside 
of  the  jacket  and  reaches  to  the  top  of  it.  It  is  there  stitched  to  the 
upper  part  of  the  shirt  along  the  upper  edge  of  the  jacket. 

REMOVABLE  JACKETS. — After  a  jacket  has  been  applied  by  any 
one  of  these  methods,  it  may  be  converted  into  a  removable  jacket 
by  splitting  it  and  furnishing  it  with  lacings  or  buckles  and  straps. 
Removable  jackets  are  not,  however,  such  efficient  supports  as  fixed 
jackets  during  the  acute  stage  of  the  disease.  They  are,  as  a  rule, 
to  be  used  in  convalescent  cases,  in  exceptional  cases  in  the  acute 
stage  when  the  skin  is  very  sensitive  and  requires  bathing,  when 
sloughs  or  excoriations  are  present,  and  in  similar  conditions. 

As  a  substitute  for  plaster  jackets,  corsets  are  made  of  leather, 
wood,  aluminum,  celluloid  gauze  dipped  in  celluloid  paste,  papier- 
mache,  and  other  materials. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


37 


There  are  certain  practical  details  with  regard  to  the  application 
of  plaster  jackets  and  removable  jackets  that  are  important. 

PLASTER-OF-PARIS  BANDAGES. — Plaster-of-Paris  jackets  depend 
for  their  durability,  lightness,  and  efficiency  largely  upon  the  material 
from  which  they  are  made  and  the  skill  with  which  they  are  applied. 
The  most  durable  bandages  are  those  made  from  slow-setting  plaster. 
The  quicker-setting  plaster  offers  distinct  advantages,  but  jackets 


FIG.  33.— Plaster  Jacket.    Front  view. 


FIG.  34.— Plaster  Jacket.     Back  view. 


made  of  it  are  more  friable  and  less  durable.  The  material  which 
the  writers  use  as  a  foundation  for  the  plaster  is  a  crinoline,  which  is 
sized  with  starch,  and  not  with  glue,  which  is  especially  prepared. 
This  crinoline  should  be  torn  into  strips,  four  yards  long  and  four 
or  five  inches  wide.  After  the  crinoline  is  torn,  the  loose  threads 
should  be  removed  from  the  edges,  and  the  strips  folded  ready  for 
the  rubbing-in  of  the  plaster. 

PLASTER. — If    a    quick-setting    jacket    is    desired    dental    plaster 
should  be  used,  and  if  a  slow-setting  bandage,  a  high-grade  of  com- 


38  ORTHOPEDIC  SURGERY 

mercial  plaster-of-Paris.  The  durability  and  the  tensile  strength  of 
the  jacket  are  increased  if  to  either  kind  of  plaster  is  added  five  per 
cent  of  Portland  cement,  thoroughly  mixed  with  the  plaster. 

The  plaster  is  incorporated  in  the  bandage  by  laying  the  crinoline 
strip  flat  on  a  table,  on  which  is  placed  a  heap  of  the  plaster.     A 


FIG.  3S-— Plaster  Jacket.     Side  view. 


FIG.  36  —  Plaster  Jacket  and  Head- 
piece.   (Wullstein.) 


handful  of  this  plaster  is  then  placed  on  the  strip  and  swept  along 
with  the  hand  or  with  a  flat  piece  of  splint  wood,  the  excess  being 
brushed  aside,  and  the  bandage  thus  impregnated  with  plaster  is  rolled 
loosely,  as,  if  it  is  tightly  rolled,  the  water  does  not  reach  the  inner 
layers.  If  it  is  desired  to  secure  bandages  of  the  highest  efficiency 
each  bandage,  after  being  rolled,  should  be  wrapped  in  three  paper 
napkins,  applied  one  at  a  time  and  folded  over  the  ends  of  the  bandage. 
After  the  third  napkin  is  put  on,  a  rubber  elastic  strap  is  placed 
around  the  end  of  the  bandage,  and  the  bandage  is  ready  for  use.  In 
this  way  the  plaster  is  all  kept  in  the  bandage  and  does  not  escape  into 
the  water. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  39 

When  the  plaster  jacket  is  to  be  applied  the  bandages  should  be 
immersed  in  a  pail  containing  at  least  eight  inches  of  warm  water. 
If  it  is  desired  to  hasten  the  setting  of  the  bandage  a  teaspoonful  of 
salt  may  be  added  to  the  water,  but  this  increased  speed  of  setting  is 
obtained  at  the  expense  of  durability.  If  it  is  desired  to  delay  the 
setting  a  teaspoonful  of  alum  or  a  small  amount  of  glue  should  be 
added  to  the  water.  When  the  bandage  is  taken  from  the  water  the 
hands  of  the  assistant  should  be  placed  over  each  end  of  it  and  it 
should  be  squeezed  until  it  no  longer  drips.  If  the  paper  napkins  are 
used  the  covered  bandage  should  be  immersed  in  the  water,  allowed 
to  soak,  squeezed,  and  the  wet  paper  then  removed  before  use. 

APPLICATION  OF  BANDAGES. — Bandages  should  be  applied  with  a 
smooth  even  pressure  and  uniform  tension  throughout  each  turn. 
There  should  never  be  reverse  turns,  and  each  layer  should  be  rubbed 
into  the  next  layer  by  the  hand.  From  eight  to  ten  layers  of  a 
properly  prepared  and  applied  bandage  are  in  general  enough  to 
make  a  strong  jacket.  Extra  resistance  may  be  secured,  and  in  many 
cases  a  lighter  jacket  constructed,  by  reinforcing  it  by  means  of  a 
plaster  rope.  A  bandage  is  taken  from  the  water  and  strips  two. or 
three  feet  long  are  unrolled.  After  four  or  five  strips  have  been 
loosened  they  are  held  by  one  end,  and  by  the  other  hand  sliding  down 
are  incorporated  into  a  plaster  rope  about  an  inch  in  diameter,  which 
is  then  laid  over  the  light  part  which  it  is  desired  to  strengthen,  and 
secured  in  place  by  circular  turns. 

When  a  jacket  is  to  be  removed  it  is  perfectly  safe,  if  a  sufficient 
layer  of  sheet-wadding  has  been  placed  under  it  in  the  line  of  intended 
removal,  to  cut  the  jacket  with  a  sharp  knife,  making  the  strokes  of 
the  knife  parallel  to  the  skin.  The  form  of  knife  most  available  for 
this  is  a  shoe  knife  with  a  blunt  point  and  a  concave  curved  edge. 
There  are  various  forms  of  plaster  shears  in  use  for  the  same 
purpose. 

REMOVABLE  JACKETS. — Although  plaster  makes  a  light  and,  when 
properly  constructed,  a  fairly  durable  jacket,  it  is  injured  by  constant 
springing  open  and  the  inner  surface  is  apt  to  be  rather  rough,  conse- 
quently various  substitutes  are  used  when  it  is  likely  that  a  removable 
jacket  will  have  to  be  worn  for  some  time.  Celluloid  forms  one  of 
the  most  acceptable  of  these.  For  the  manufacture  of  this  form  of 
jacket  the  plaster-of-Paris  jacket  is  removed,  and  filled  with  a  thick 
mixture  of  plaster-of-Paris  and  water.  The  mould  is  then  removed 
and  the  cast  smoothed,  dried,  and  shellacked. 

CELLULOID. — An  undervest  is  then  placed  over  the  cast,  and  strips 


40  ORTHOPEDIC  SURGERY 

of  crinoline,  cheesecloth,  or  stockinet  laid  over  the  undervest.  These 
strips  are  then  painted  with  a  mixture  consisting  of  celluloid  chips 
dissolved  in  acetone.  This  paste  is  allowed  to  dry,  and  other  coats 
are  applied  so  long  as  the  cloth  material  takes  up  mere  celluloid. 
When  it  ceases  to  be  absorbed  more  cloth  is  laid  on  in  the  same 
way,  and  the  process  is  repeated.  The  number  of  layers  necessary 
will  depend  upon  the  thickness  of  the  material.  The  jacket  is  left 
on  the  cast  until  it  is  thoroughly  dry  inside  and  out.  When  it  is 
thoroughly  dry  it  is  cut  and  removed,  the  inside  is  painted  with  cellu- 
loid, the  edges  trimmed  and  bound  with  leather,  the  splint  is  perfo- 
rated with  holes  throughout,  and  straps,  studs,  or  lacings  are  put 
along  the  edges. 

LEATHER  SPLINTS  AND  JACKETS. — Moulded  leather  jackets  are 
made  from  oak-tanned  English  leather,  which  should  not  be  "  filled  " 
or  "  stuffed."  The  leather  is  cut  of  the  desired  pattern  and  softened  by 
soaking  in  water.  When  it  is  thoroughly  flexible  it  is  stretched  over 
a  plaster  cast  of  the  limb  or  trunk  and  made  to  conform  to  all  the 
curves  of  it.  After  being  shaped,  it  is  allowed  to  dry  on  the  cast  and 
removed,  as  it  will  retain  the  shape  which  it  assumed  when  wet  if  it 
is  thoroughly  dry.  If  it  is  wished  to  stiffen  the  leather  in  order  to 
secure  a  firmer  support,  especially  in  the  case  of  jackets,  the  moulded 
leather  splint  is  painted  with  hot  bayberry  wax  until  it  ceases  to 
absorb  it,  and  it  is  then  allowed  to  dry.  The  jacket  is  now  painted  with 
a  solution  of  shellac  inside  and  outside  and  allowed  to  dry  thoroughly. 
If  desired  such  jackets  or  splints  can  be  reinforced  with  strips  of 
steel  fastened  on  the  outside  and  riveted  to  the  jacket.  Jackets  should 
be  provided  with  leather  lacings  or  straps  and  buckles. 

LEATHER  AND  CELLULOID  JACKETS. — A  fairly  durable  and  light 
jacket  may  be  made  by  a  combination  of  these  two  processes.  A 
leather  jacket,  too  light  to  be  of  much  support,  is  made  as  described 
and  thoroughly  dried  cut.  The  inner  surface  of  the  jacket  is  then 
painted  with  the  celluloid  mixture  described,  over  strips  of  crinoline 
or  cheesecloth.  The  jacket  is  kept  on  the  cast  in  the  interval  between 
the  painting  in  order  that  no  warping  may  occur,  and  as  many  layers 
of  cloth  are  painted  on  as  may  seem  necessary  to  secure  the  desired 
firmness.  When  the  last  layer  has  been  applied,  enough  celluloid  is 
painted  on  to  give  a  smooth  surface  to  the  inside  of  the  jacket. 

TREATMENT  BY  STEEL  APPLIANCES. 

The  basis  of  ambulatory  treatment  of  Pott's  disease  in  the  sub- 
acute  or  convalescent  stage  is  fixation,  as  complete  as  possible,  of 


TUBERCULOUS  DISEASE  OF  THE  SPINE  41 

the  spine  in  as  advantageous  a  position  as  obtainable.     This  may  be 
done  by  means  of  a  properly  made  appliance. 

As  the  chief  motion  of  the  spine  to  be  guarded  against  is  the  for- 
ward motion,  the  principle  of  the  appliance  being  that  of  an  antero- 
posterior  support.  The  construction  and  application  of  a  brace  should 
be  superintended  directly  by  the  surgeon,  and  not  relegated  to  an 


FIG.  37. — Antero-Posterior  Brace  for  Dorsal  Pott's 
Disease  Applied. 


FIG.  38 — Antero-Posterior  Brace  for 
Pott's  Disease;  showing  Apron 
and  Leather  Gorget. 


instrument-maker.  For  the  construction  of  a  splint  a  cardboard 
tracing  of  the  back  should  be  made  at  one  side  of  the  spinous  processes. 
The  simplest  antero-posterior  apparatus  consists  of  two  uprights  of 
annealed  steel.  The  uprights  are  joined  together  below  by  an  inverted 
U-shaped  piece  of  steel  which  runs  as  far  down  en  the  buttock  as  possi- 
ble without  reaching  the  chair  or  bench  when  the  patient  sits  down.  At 
the  top  the  uprights  end  in  shoulder  pieces  running  over  the  shoulders. 


42  ORTHOPEDIC  SURGERY 

The  brace,  after  being  put  together  but  before  being  finished, 
should  be  tried  on  the  patient,  who  should  be  lying  on  his  face.  Any 
alteration  necessary  in  the  curves  of  the  steel,  in  order  to  have  the 
appliance  fit  closely  to  the  back  along  its  whole  length,  can  be  made 
with  wrenches.  The  brace  can  be  faced  with  hard  rubber  or  covered 
smoothly  with  leather.  An  accurate  fit  is  essential;  the  covering  is 
merely  a  matter  of  detail. 

Accurately  fitting  pad  plates  covered  with  felt  and  leather  or  hard 
rubber  are  needed,  but  in  some  instances,  the  bars  of  the  brace,  if 
well  padded  at  the  points  of  greatest  pressure,  answer  every  purpose. 
Buckles  are  needed  at  various  levels. 

If  properly  designed,  the  appliance  will  press  firmly  at  the 
deformity,  i.e.,  the  pad  plates  and  pressure  should  be  uniform  at  this 
point  and  closely  fitted  to  the  contour  of  the  deformity  in  all  places. 
The  appliance  will  also  touch  necessarily  at  the  top  and  bottom,  but 
the  chief  pressure  should  be  at  the  kyphus.  It  should  be  borne  in  mind 
that,  besides  accuracy  of  fit  and  proper  design,  it  is  of  importance  that 
the  apparatus  be  stiff  enough  net  to  yield  as  the  weight  of  the  trunk 
falls  upon  it,  inasmuch  as  yielding  involves  intervertebral  pressure. 

It  is,  of  course,  essential  that  the  trunk  be  properly  secured  to 
the  brace.  This  can  be  done  in  part  by  means  of  an  apron,  of  cloth 
or  leather,  which  covers  the  front  of  the  trunk,  the  abdomen,  and 
the  chest,  reaching  from  the  clavicles  nearly  to  the  symphysis  pubis. 
The  apron  is  provided  with  webbing  (non-elastic)  straps,  which  are 
fastened  into  buckles  attached  to  the  brace.  Padded  straps,  passing 
from  the  top  of  the  brace  around  the  arms,  under  the  axillae,  and 
attached  to  buckles  in  the  middle  of  the  brace,  help  to  secure  it;  but  the 
scapulae,  being  movable,  cannot  be  relied  upon  alone  to  fix  the  trunk, 
and  the  apron  must  be  furnished  with  straps  at  the  top,  which  pass 
over  the  shoulders  to  buckles  in  the  top  of  the  brace. 

In  adults  it  is  often  convenient  to  have  the  apron  split  down  the 
front  and  provided  with  webbing  straps  and  buckles,  so  that  the 
patient  can  adjust  it  himself  by  tightening  the  straps  in  front. 

To  secure  a  proper  hold  upon  the  upper  segment  of  the  body  in 
dorsal  disease  some  unyielding  and  rigid  chest-piece  is  necessary. 

The  brace  should  be  worn  day  and  night,  and  removed  daily  that 
the  back  may  be  bathed.  \Yhile  the  brace  is  off,  the  patient  should 
lie  on  the  face  or  the  back.  On  no  account  should  he  sit  erect.  The 
back,  after  being  washed,  should  be  rubbed  with  alcohol  and  then 
powdered  with  face  powder,  corn  starch,  or  fuller's  earth.  The  brace 
should  then  be  applied  and  buckled  tightly  into  place. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  43 

In  applying  the  brace  the  patient  should  lie  upon  his  face,  and 
the  apron  be  spread  under  him.  The  brace  should  then  be  placed  in 
position  upon  the  bare  back,  or  upon  a  thin,  smooth  cloth  without 
wrinkles,  and  the  apron  strapped  to  it  as  tightly  as  is  possible.  The 
more  tightly  the  two  are  strapped  together,  the  more  thorough  is 
the  fixation.  The  position  of  the  straps  and  their  number  will  vary 
in  cases  according  to  the  situation  of  the  disease,  etc.  The  brace 


FIG.  39. — Apron  for   Use  with  Antero- Posterior   Spinal   Support. 

must,  of  course,  if  it  is  to  exert  pressure,  always  be  straighter  than 
the  spine. 

Head  Supports — In  the  upper  region,  as  elsewhere,  it  is  desirable 
to  prevent  the  weight  of  the  head  from  falling  upon  the  diseased 
bodies  of  the  vertebrae. 

An  efficient  arrangement  is  one  devised  by  Dr.  Taylor,  of  New 
York;  an  ovoid  steel  ring  passes  around  the  neck,  made  so  that  it 
.can  open,  and  be  secured  when  closed,  and  arranged  so  that  it  can 
serve  as  a  rest  for  the  chin,  and  so  that  pressure  can  also  be  exerted 
on  the  occiput.  This  collar  has  at  the  front  a  hard-rubber  chin  piece 
accurately  shaped  to  the  chin,  and  may  have  at  the  back  a  stiff  piece 
of  sole  leather  projecting  up  from  the  back  of  the  ring.  This  steadies 
the  head  and  prevents  the  pressure  of  the  occiput  against  the  back 
of  the  headpiece.  This  collar  at  the  back  plays  on  a  pivot,  allowing 
lateral  motion  of  the  head.  The  pivot  is  attached  to  the  usual  back 
brace,  and  can  be  raised  or  lowered,  as  it  is  desired  to  increase  or 


44 


ORTHOPEDIC  SURGERY 


diminish  the  upward  pressure  on  the  head.  This  appliance  requires 
care  and  skill  in  application,  and  is  useless  unless  properly  fitted. 

Other  forms  of  head  support  have  been  tried  from  time  to  time. 

A  head  support,  devised  by  Goldthwait,  affords  good  fixation, 
and  it  is  serviceable  in  cases  in  which  there  is  excessive  sensi- 
tiveness of  the  spine,  due  to  cervical  or  very  high  dorsal  disease. 


FIG.    40. — Oval    Ring    Head    Support    Added    to    the    Antero-Posterior    Support. 

Cellars  of  various  sorts,  unattached  to  any  other  appliance,  have 
been  used,  which,  pressing  on  the  chin  and  occiput  above,  and  on 
the  clavicles,  sternum,  and  shoulders  below,  transfer  the  weight  in 
part  from  the  intermediate  cervical  vertebra?  and  check  the  forward 
bending  of  the  cervical  region.  These  collars  can  be  made  of  plaster- 
of-Paris,  but  are  cumbersome  and  unsightly.  As  a  substitute  a 
stiffened  leather  collar  can  be  made,  using  sole  leather  stiff  and 
stretched  over  a  mould  from  a  plaster-of-Paris  neck  cast. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


45 


In  all  forms  of  head  supports,  if  worn  for  a  long  time,  a  certain 
amount  of  recession  of  the  chin  takes  place,  as  the  growth  of  the 
lower  jaw  is  in  a  measure  temporarily  interfered  with.  The  jaw 
gradually  resumes  its  shape  after  removal  of  the  head  support. 

When  careful  and  skilled  attention  can  be  applied  to  the  construc- 


FIG.  41. — Taylor  Back  Brace  with  Oval 
Ring.     Head  support  applied. 


FIG.    42.. 


-Antero-Posterior   Brace    with    Bent 
Wire  Head  Support. 


tion,  attention,  and  needed  alteration  of  a  brace,  it  will  be  found  of  great 
efficiency  in  the  treatment  of  Pott's  disease  in  the  convalescent 
stage. 

The  chief  objection  to  the  use  of  mechanical  appliances  as  a  method 
of  treatment  is  that  care  and  special  skill  are  required,  not  only  in  the 
application  of  braces,  but  in  the  inspection  and  management  of  the 
cases. 

If  the  trunk  is  not  thoroughly  fixed  by  the  straps.,  etc.,  of  the 
appliance,  the  brace,  becomes  simply  a  splint  of  steel  laid  upon  the 
back,  and  not  a  therapeutic  agent. 


46 


ORTHOPEDIC  SURGERY 


RECTIFICATION  OF  THE  DEFORMITY. 

Forcible  correction  of  the  deformity,  with  or  without  anaesthesia, 
is  a  method  which  has  been  discarded  for  methods  of  gradually 
straightening. 

But  although  the  correction  of  deformity  by  the  use  of  violence 

is  irrational  and  may  be  seriously 
injurious,  the  employment  of  mod- 
erate force  in  correction  is  fre- 
quently beneficial. 

The  mechanical  means  for  rec- 
tification are  those  already  men- 
tioned as  of  use  in  the  application 
of  plaster  jackets.  Rectification 
judiciously  applied  is  beneficial  in 
all  active  cases  of  Pott's  disease. 
Pressure  symptoms  will  be  re- 
lieved and  in  seme  instances  pa- 
ralysis checked. 

It  must  also  be  understood  that 
after  correction  a  relapse  of  the 
curve  will  take  place  unless  the 
corrected  position  is  maintained  by 

adequate  fixed   appliances  until   the   spine   is   well   cicatrized   in   the 
corrected  position. 

In  favorable  cases  a  gradual  reduction  of  the  deformity  is  effected. 

OPERATIONS  ON  THE  SPINE. 

( i )  Operations  on  the  vertebral  column  may  be  done  on  account  of 
complications  or  in  an  attempt  to  shorten  the  course  of  the  disease. — 
Operative  measures  are  necessary  under  exceptional  circumstances  for 
the  direct  examination  of  the  diseased  vertebral  bodies  and  the  re- 
moval or  drainage  of  the  diseased  bcne,  it  must  be  remembered  that  in 
any  event  the  vertebral  bodies  are  mere  or  less  inaccessible,  and 
that  such  operations  are  net  likely  to  prove  of  benefit  as  routine 
measures. 

In  the  cervical  region  the  anterior  surfaces  of  the  bodies  of  the 
vertebra?  may  be  reached  either  through  the  mouth,  by  a  lateral 
incision,  or  by  incision  in  the  back  of  the  neck.  Through  the  mouth 
the  operating  space  is  small,  the  proceeding  difficult  on  account  of 
the  anaesthetic,  and  the  dangers  of  infection  are  evident.  This  method 


FIG.  43. — Anterior  Head  Support. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


47 


makes  accessible  only  the  second,  third,  and  fourth  vertebral  bodies. 
The  lateral  method  is  preferable.  An  incision  is  made  along  the  poste- 
rior border  of  the  sternomastoid  muscle;  the  sternomastoid  and 
omohyoid  are  raised  and  the  space  made  by  the  splenius  and 
omohyoid  is  reached.  The  dissection  is  carried  through  the  longus 
colli,  and  the  vertebral  arteries  are  avoided. 

In   the  dorsal   region  exploration  may  be  advisable   in  case   an 
abscess  in  the  posterior  mediastinum  is  suspected.     In  such  cases  the 


FIG.  44. — Thomas    Leather   Collar. 


FIG.  45.— Collar  and  Chest-piece  for  Cervical 
Pott's  Disease. 


operation  of  costo-transversectomy  should  be  dene.  An  incision  at 
the  side  of  the  spinous  processes  uncovers  the  tops  of  the  transverse 
processes  and  the  bases  of  the  ribs.  The  ribs  are  divided  at  the  tuber- 
osities  and  the  posterior  part,  with  the  transverse  .process,  removed. 
The  spine  is  then  reached  by  the  finger. 

In  the  lumbar  region  an  incision  is  made  from  the  twelfth  rib  to 
the  ilium,  two  and  one-half  inches  outside  of  the  median  line;  the 
incision  reaches  to  the  border  of  the  quadratus  lumborum  and  the  tips 
of  the  transverse  processes  should  be  felt.  The  dissection  is  carried 
down  to  the  psoas  muscle;  some  of  the  fibres  of  this  muscle  are 
detached  with  care  from  one  transverse  process.  The  finger  intro- 


48 


ORTHOPEDIC  SURGERY 


duced  reaches  without  difficulty  the  anterior  surface  of  the  vertebral 
bodies.  The  finger  can  strip  up  the  psoas  muscle  through  this  incision 
and  explore  the  vertebral  bodies.  The  vertebral  canal  should  not  be 
opened. 

(2)  Osteoplastic  Operations  Aimed  at  Shortening  the  Disease. — 
Of  late  operations  have  been  advocated  having  for  their  object  the 
fixation  of  the  diseased  area  of  the  spine  by  operations  on  the  spinous 
processes  and  lamime.  Many  years  ago  it  was  proposed  by  Hadra 
to  wire  together  the  spinous  processes  opposite  the  disease,  many  years 


73     74    77    1664 


1869     70  75  76         1871    73  76 


1869    70    76  77 


FIG.  46. — Tracings  showing  Results  of  Brace  Treatment  as  Carried  Out  by  Dr.  C.  F.  Taylor. 
/,  Two  and  three-quarters  years,  first  and  second  lumbar  disease,  five  years'  treatment; 
//,  eight  years,  eleventh  and  twelfth  dorsal,  four  years'  treatment;  ///,  four  years,  first 
lumbar,  ten  years'  treatment;  IV,  three  and  one-half  years,  six  years'  treatment;  V,  five 
years,  twelfth  dorsal,  first  and  second  lumbar,  nine  year's  treatment;  VI,  five  and  one- 
half  years,  sixth  and  eighth  dorsal,  four  years'  treatment;  VII,  about  eighteen,  dorso- 
lumbar,  eight  years'  treatment;  I' III,  nine  years,  seventh  to  ninth  dorsal,  teven  years' 
treatment;  IX,  twenty  years,  five  years'  treatment;  X,  ten  years,  eight  years'  treatment. 
(Dates  are  given  with  tracings;  the  age  given  is  that  at  which  treatment  was  begun.) 

later  Chipault  advocated  fastening  them  together  by  means  of  silk. 
Lange  advocated  the  use  of  subcutaneous  metal  rods,  but  the  osteo- 
plastic  operations  of  Hibbs  and  Albee  have  found  the  greatest 
favor. 

The  Hibbs  operation  a  is  performed  by  making  an  incision  in  the 
median  line  opposite  the  diseased  region  reaching  above  and  below 
to  sound  vertebne.  The  spinous  processes  are  exposed  and  denuded 
of  periosteum.  The  interspinous  ligaments  are  divided  and  the  peri- 
osteum peeled  back  in  a  sheet  on  both  sides  as  far  as  the  transverse 
processes.  The  spinous  processes  are  then  cut  nearly  through  at  their 
bases  and  broken  down,  to  lie  closely  on  each  other,  and  the  periosteum 
1  Hibbs:  Journal  Am.  Med.  Assn.,  1912,  lix.,  433. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  49 

is  then  united  as  a  tube  over  them.  Fixation  is  desirable  for  some 
months. 

The  Albee  operation  l  consists  in  exposing  the  spine  opposite  the 
deformity,  reaching  to  sound  vertebrae  above  and  below.  The  spinous 
processes  are  split  by  a  chisel  and  the  soft  parts  divided  to  form  a 
continuous  groove,  which  should  include  one  or  two  sound  vertebrae 
at  each  end.  The  tibia  is  then  exposed  and  a  triangular  graft  of  the 
desired  length  cut  from  the  front  edge  of  the  bone.  This  graft  is 
then  inserted  in  the  cleft  in  the  spinous  processes,  being  trimmed  to 
fit  the  curve,  and  is  secured  by  heavy  stitches  through  the  soft  parts 
at  the  side  of  the  cleft.  Fixation  afterward  for  some  months  is 
desirable. 

It  is  too  early  to  estimate  the  real  value  of  these  operations.  Their 
aim  is  rational,  to  splint  the  spine  opposite  the  site  of  disease,  the 
risk  to  life  is  not  great,  and  in  some  cases  the  result  is  brilliant  and 
cessation  of  symptoms  occurs  almost  at  once.  But  in  other  cases 
relapses  occur  in  a  few  months  apparently  due  to  an  extension  of 
disease  and  perhaps  sometimes  to  too  short  a  splint.  Again  the  late 
effect  of  splinting  a  large  part  of  a  growing  spine  cannot  be  foretold. 

In  the  opinion  of  the  writers  at  present  the  operations  should  be 
limited  to  those  cases  where  good  mechanical  treatment  has  failed  or 
where  it  cannot  be  carried  out.  They  should  not  be  performed  on 
very  young  children,  nor  in  cases  of  disease  in  the  cervico-dorsal  or 
lower  lumbar  region.  Later  on  it  will  be  possible  to  decide  as  to  the 
terminal  results  of  these  operations. 

TREATMENT  OF  ABSCESS. 

Abscesses  may  be  treated  by  expectancy  or  by  operation. 

(1)  Expectancy. — Under  proper  treatment  early  abscesses  may 
subside  and  be  absorbed  without  detriment  to  the  patient.  , 

Recumbency  under  the  best  mechanical  conditions,  preferably  in 
the  open  air  day  and  night,  will  favor  the  tendency  to  absorption. 
Aspiration  will  diminish  the  size  of  an  abscess,  but  if  it  does  not  tend 
to  absorb  under  the  conditions  mentioned,  and  especially  if  it  shows 
a  tendency  to  increase,  it  is  better  not  to  temporize,  but  to  incise. 

(2)  Operation. — When   abscesses    increase    rapidly,    or    for  any 
reason  seem  an  injury  to  the  patient,  incision  is  to  be  considered. 

Incision  of  an  abscess  should  be  made  under  thorough  aseptic  pre- 
cautions, and  as  complete  drainage  as  possible  secured ;  but  it  must 
be  remembered  that  owing  to  the  depth  of  the  origin  of  abscesses  in 
1  Albee:  Journal  Am.  Med.  Assn.,  1911,  Ivii.,  885. 


50  ORTHOPEDIC  SURGERY 

Pott's  disease  perfect  drainage  is  not  always  as  easily  furnished  as  in 
more  superficial  abscesses.  It  is  therefore  desirable,  especially  in  adults, 
to  delay  incision  longer  than  would  otherwise  be  surgically  indicated. 

It  must  be  remembered,  in  the  treatment  of  tuberculous  abscesses, 
that  after  incision  mixed  infection  always  occurs  if  the  opening  con- 
tinues to  discharge.  In  spite  of  all  precautions  the  writers  have  never 
been  able  to  keep  such  areas  bacteriologically  sterile  indefinitely. 

In  retropharyngeal  and  cervical  abscesses,  however,  drainage  can 
ordinarily  be  readily  secured.  In  dorsal  abscesses  an  incision  in  the 
back  is  frequently  sufficient ;  but  in  some  instances  it  will  be  necessary 
to  perform  costo-transversectomy  to  secure  perfect  drainage.  In 
lumbar  and  iliac  abscesses  it  may  be  necessary,  owing  to  the  depth 
of  their  origin,  to  incise  both  in  front  and  behind,  which  can  be  done 
with  care  without  opening  the  peritoneal  cavity. 

Psoas  abscess  may  be  opened  in  the  loin  or  in  the  iliac  fossa,  or 
in  both  places.  Drainage  may  be  made  with  a  strip  of  gauze  cr  a 
rubber  tube  and  the  dressing  kept  sterile  as  long  as  possible.  After 
incision  curettage  is  not  desirable,  as  it  is  impossible  to  remove  all 
of  the  diseased  material  and  unnecessary  traumatism  is  to  be  avoided. 

A  retropharyngeal  abscess  is  best  opened  by  passing  into  the  mauth 
a  bistoury  wound  to  within  half  an  inch  of  its  point  with  cotton, 
and  cutting  freely,  using  the  finger  as  a  guide.  The  child  should  be 
held  face  downward  in  order  that  the  pus  may  not  enter  the  trachea, 
and  plenty  of  swabs  should  be  at  hand  to  keep  the  mouth  clear,  for 
the  gush  of  pus  is  sometimes  considerable.  Such  abscesses  may  also 
be  opened  by  lateral  incisions  from  the  outside. 

Treatment  of  Psoas  Contraction. — When  flexion  of  one  or  both 
thighs  has  come  on  it  is  net  likely  to  diminish  spontaneously,  and  if 
the  condition  is  allowed  to  go  untreated,  such  contractions  may  become 
permanent. 

In  the  early  stages  the  child  should  be  put  to  bed  on  a  frame.  A 
light  extension  should  be  applied  to  the  leg  with  pulley  extension, 
and  the  pulley  should  be  gradually  lowered  until  the  leg  is  straight  and 
the  flexion  overcome.  In  cases  in  which  the  flexion  has  existed  only 
a  few  weeks  or  months,  this  is  generally  easily  accomplished  in  two 
or  three  weeks.  If  not,  or  if  a  more  rapid  method  is  desired  in  the 
first  instance,  the  child  should  be  anaesthetized  and  the  leg  straightened 
by  force  and  retained  by  plaster-of-Paris.  If  this  cannot  be  done 
with  the  use  of  moderate  force,  it  is  better  to  divide  and  cut  the  fascia 
and  the  contracted  bands — an  operation  which  cannot  often  be  done 
thoroughly  subcutaneously,  for  there  are  many  deep  bands. 


UBFfcRY  OF 


TUBERCULOUS  DISEASE 

Ffr/SfCfMJr;  /i'-^f 

TREATMENT  OF  PARALYSIS. 

When  paralysis  is  threatened,  the  patient  should  be  put  to  bed  on 
a  frame  so  padded  as  to  press  upon  the  deformity  and  hold  the  verte- 
brae somewhat  separated.  In  dorsal  cases  traction  may  be  added.  An 
attack  may  thus  often  be  averted. 

\Yhen  paralysis  is  present,  a  plaster  jacket  should  be  applied  in 
strong  hyperextension  of  the  spine  at  the  seat  of  the  deformity  (by 
one  of  the  methods  mentioned),  and  the  patient  should  be  kept 
recumbent  until  the  paralysis  begins  to  disappear. 

The  tendency  of  paralysis  is  strongly  toward  recovery  under 
favorable  conditions  of  treatment. 

Drugs  are  of  little  or  no  value,  and  it  is  not  possible  to  attach 
importance  to  the  use  of  the  cautery  or  of  counter-irritants. 

Laminectomy.  —  A  spicule  of  bone  or  an  intraspinal  abscess  may 
be  the  source  of  pressure  at  any  stage  of  the  disease,  and  in  such 
cases,  of  course,  operation  is  demanded.  In  cases  of  long  standing, 
however,  in  which  the  paralysis  has  become  very  extensive  and  has 
involved  sensation,  laminectomy  is  of  doubtful  utility. 

The  operation  consists  in  cutting  down  upon  the  spinous  processes 
in  the  region  of  the  deformity,  the  incision  being  slightly  to  one  side 
of  the  centre,  so  that  the  resulting  cicatrix  will  not  be  unduly  pressed 
upon  during  recumbency.  All  the  soft  tissues  are  then  stripped  up 
with  a  periosteal  knife,  until  the  laminae  are  exposed.  The  spinous 
processes  are  then  removed  with  bone  forceps  over  the  affected  area. 
Laminectomy  forceps  are  then  used  to  cut  away  all  of  the  laminae 
covering  the  cord  at  the  seat  of  pressure.  The  dura  may  or  may  net 
be  opened.  A  probe  is  then  passed  up  and  down  the  spinal  canal, 
to  be  sure  that  all  pressure  is  removed,  and  the  wound  is  dressed.  The 
patient  should  be  laid  on  the  face  after  operation  if  it  is  more  com- 
fortable. 

The  operation,  however,  has  no  place  in  the  treatment  of  Pott's 
disease  until  the  conservative  measures  have  been  faithfully  tried  over 
a  sufficient  period  of  time  —  measures  which  in  most  cases  will  prove 
efficient  and  successful  in  the  relief  of  the  paralysis. 


CHAPTER  III. 

TUBERCULOUS  DISEASE  OF  THE  HIP. 

Tin-:  term  hip  disease  by  common  usage  is  applied  to  chronic 
tuberculous  ostitis  of  the  head  of  the  femur  or  of  the  acetabulum. 

PATHOLOGY. 

The  pathology  of  hip  disease  in  general  does  not  differ  from  that 
of  tuberculous  disease  of  bone  which  has  already  been  referred  to. 

The  head  of  the  femur  is  the  primary  seat  of  disease,  in  a  majority 
of  the  cases  the  epiphysis  or  juxta-epiphyseal  region  being  the  part 
attacked.  In  about  twenty-five  per  cent  of  the  cases  the  primary 
focus  is  in  the  acetabulum. 

When  once  the  acetabulum  has  become  diseased  either  primarily 
or  secondarily,  enlargement  of  it  is  apt  to  take  place.  The  irritated 
pelvic  femoral  muscles,  which  are  in  a  state  of  tonic  contraction,  crowd 
the  head  of  the  femur  against  the  upper  and  back  border  of  the 
acetabulum ;  under  this  continual  pressure  absorption  of  that  portion 
of  the  rim  of  the  acetabular  cavity  takes  place  with  an  actual  enlarge- 
ment of  the  cavity  from  below  upward.  This  so-called  migration  of 
the  acetabulum  is  one  cause  of  shortening  of  the  limb,  and  measure- 
ment will  show  that  the  trochanter  lies  above  Xelaton's  line. 

The  changes  in  the  head  of  the  femur  are  chiefly  the  result  of 
ostitis  and  pressure. 

Partial  destruction  of  the  softened  head  of  the  femur  may  lead 
to  a  shortening  of  the  limb  and  to  an  elevation  of  the  trochanter 
above  its  proper  level.  The  wearing  away  of  the  acetabulum  produces 
the  same  result ;  but  true  dislocation  is  rare,  except  in  the  more  acute 
cases. 

A  typical  specimen  from  a  fairly  advanced  case  of  hip  disease 
shows  a  reddened  and  thickened  synovial  membrane,  often  with 
granulations;  the  cartilage  is  gone  from  the  head  of  the  femur  or 
hangs  in  shreds;  sometimes  the  whole  cartilage  may  be  lifted  from 
the  bone  by  a  layer  of  granulations. 

Perforation  of  the  floor  of  the  acetabulum  may  take  place.  Inside 

52 


TUBERCULOUS  DISEASE  OF  THE  HIP 


53 


of  the  pelvis  a  dense  wall  of  fibrous  tissue  and  thickened  periosteum 
shuts  off  the  head  of  the  femur  or  the  contents  of  the  joint  from  the 
pelvic  cavity. 

A  natural  cure  results  in  one  of  two  ways :  by  the  absorption  or 
calcification  of  the  tuberculous  tissue  at  an  early  or  a  late  stage  of 


FIG.  47. — Erosion  of  the  Upper  Part  of  the  Acetabulum.      (Warren  Museum.) 

the  disease;  or  by  its  evacuation  and  discharge  by  an  external  open- 
ing. The  suppuration  which  comes  later  seems  to  be  nature's  effort  to 
eliminate  the  diseased  material,  and  it  is  the  common  method  by  which 
spontaneous  cure  results  when  it  does  occur.  This  late  stage  of  the 
disease  is  characterized  by  malpositions  and  shortening  of  the  limb 
and  much  impairment  of  the  general  condition  in  most  cases. 
When  spontaneous  cure  does  occur  it  is  usually  with  an  ankylosed 
joint. 


54 


ORTHOPEDIC  SURGERY 


CLINICAL    HISTORY. 


Early  Symptoms. — The  beginning  of  the  affection  is  most  often 
gradual  and  insidious,  but  at  times  it  begins  so  abruptly,  according  to 


FIG.     49. — Hip.       Excised     head     of     femur. 

FIG.   48. — Focus   in    Head   of    Femur.  Articular    cartilage    turned    up    at   one    side 

shows  tuberculous  hone  beneath.  Primary 
focus  was  in  acetabulum.  a,  Head  of 
femur,  surface  tubercles;  b,  elevated  carti- 
lage. (Nichols.) 

the  parents'  account,  as  to  suggest  a  traumatic  origin.  The  child  will 
be  noticed  to  limp  at  times  with  intervals  of  comparative  freedom 
from  lameness.  This  lameness 
increases,  and  it  will  be  found  that 
the  patient  is  inclined  to  strike  the 
ball  of  the  foot  rather  than  the 
heel  in  walking;  although  the 
heel  can  be  put  down  to  the  floor, 
yet  instinctively  the  knee  is 
slightly  bent  and  the  heel  raised 
when  the  weight  of  the  trunk  falls 
on  the  hip.  There  is  a  certain 
amount  of  stiffness  of  gait  appar- 
ent in  the  morning  when  the  patient  first  gets  out  of  bed,  and  after 
sitting  for  a  while;  this  passes  away  after  the  patient  has  walked  or 


Fir,.  50.  —  Acetabulum  S°en  from  Outside. 
<7,  Tuberculous  granulations;  b,  tuberculous 
cavity.  (Nichols.) 


TUBERCULOUS  DISEASE  OF  THE  HIP 


55 


played  about.  At  night,  as  a  rule,  the  limp  is  less  than  in  the  morn- 
ing. The  limp  can  perhaps  best  be  described  as  a  very  slight  stiffness 
and  a  disinclination  to  bear  prolonged  weight  upon  the  affected  limb. 
If  the  child  be  inspected  it  will  be  seen  that  in  standing  the  knee 
of  the  affected  side  is  often  flexed  slightly,  the  pelvis  being  tipped 


'a 


FIG.    51. — Head    of    Femur    Eroded,    Partly    Destroyed,    Partly    Dislocated.      Fibrous    ankylosis. 
a,  Head  of  femur;  b,  eroded  head  of  femur;  c,  ankylosis;   d,  acetabulum.      (Nichols.) 

and  the  thigh  slightly  abducted.  The  tilting  of  the  pelvis  and  abduc- 
tion of  the  thigh  may  be  so  slight  that  it  is  scarcely  noticeable,  except 
by  the  deviation  from  the  median  line  of  the  fold  between  the  two 
buttocks.  In  girls  the  vulva  on  the  affected  side  may  be  lower  than 
on  the  other  side. 

Pain  at  this  stage  is  very  often  absent,  and  if  present  is  noted  as 
night  cries,  to  which  allusion  will  be  made. 

In  the  early  part  of  the  disease  pain  at  night,  stiffness,  and  limping 
are  the  chief  symptoms.  Then  follow  malpositions  of  the  limb,  more 
severe  disability,  and  perhaps  greater  pain  and  sensitiveness. 


ORTHOPEDIC  SURGERY 


Succeeding  the  deformities  which  have  just  been  described,  one 
may  find  abscess  formation  and  the  development  of  sinuses;  and  this 
stage  of  the  affection  will  hardly  have  been  reached  without  consid- 
erable constitutional  deterioration,  which  may  become  severe. 

Lameness. — From  being  at  first  scarcely  perceptible,  the  lameness 
increases  and  the  limp  becomes  very  noticeable.  In  very  acute  cases 
pain  may  become  so  severe  that  the  child  will  refuse  to  use  the  leg, 


Fir,.      52. — Obliteration     of     Gluteal 
Fold  in  Hip  Disease  of  Right  Side. 


Fie.     S3- — Position     Assumed    in     Standing, 
with    Slight   Abduction   of   the   Right   Leg. 


or  malposition  of  the  leg  may  come  on  rapidly  and  the  limp  may  on 
that  account  become  excessive:  but  in  general  the  child  walks  without 
pain,  though  perhaps  limping  badly.  Until  the  late  stages  of  the  dis- 
ease lameness  is  not  due  to  bone  shortening. 

Pain. — As  the  affection  progresses,  pain  in  the  knee  and  sensitive- 


TUBERCULOUS  DISEASE  OF  THE  HIP  57 

ness  to  jarring  the  limb  may  become  prominent  symptoms.  An  uncon- 
scious protection  of  the  joint  may  be  noticed  in  the  movement  of  the 
patient ;  the  foot  of  the  well  limb  may  be  placed  under  the  lower  part 
of  the  other  leg  when  it  is  to  be  suddenly  lifted  by  the  patient,  as  from 
the  floor  to  the  bed,  or  from  the  bed  to  the  floor,  or  in  moving  from 
one  side  of  the  bed  to  the  other. 

In  manipulating  the  leg  at  this  stage  pain  may  follow  the  slightest 
jar  to  the  joint,  or,  on  the  other  hand,  the  joint  may  be  perfectly  stiff 
from  muscular  spasm  and  yet  manipulation  may  be  wholly  painless. 
In  other  cases  motion  in  a  certain  arc  is  possible  without  causing  pain, 


FIG.    54. — Instinctive   Effort  at  Traction   in   Acute   Disease  of  the   Left   Leg.      (Fisk    Prize   Fund 

Essay.) 


but  when  the  limits  of  this  arc  are  reached,  further  motion  becomes 
painful  or  is  prevented  by  muscular  fixation.  The  sensitiveness  of 
the  joint  may  become  so  great,  when  an  acute  stage  supervenes,  that 
the  slightest  movement  of  the  patient  or  jar  of  the  bed  or  room  causes 
extreme  suffering.  This  stage  may  come  suddenly  and  gradually  pass 
away,  the  pain  diminishing  by  degrees  under  the  enforced  treatment 
of  rest,  or  it  may  be  persistent.  A  characteristic  position  is  frequently 
taken  by  the  patient,  who  places  the  well  foot  on  the  dorsum  of  the 
foot  of  the  affected  limb,  exerting  pressure  away  from  the  acetabulum. 
Pain  may  be  absent  at  any  or  all  stages  of  the  disease,  and  is  not  a 
diagnostic  sign  for  or  against  the  presence  of  hip  disease.  Sensitive- 
ness may  be  absent,  upon  which  condition,  however,  at  any  time  a 
sensitive  condition  of  the  joint  may  supervene.  The  pain  is  often 
remittent,  and  here,  as  in  all  the  symptoms  of  this  affection,  marked 
remissions  may  occur.  The  location  of  the  pain  is  variable,  but  is 
generally  referred  to  the  inside  and  front  of  the  thigh  near  the  knee 
or  directly  at  the  knee-joint.  The  intimate  relations  a  id  anastomoses 


58  ORTHOPEDIC  SURGERY 

of  the  sciatic,  obturator,  and  anterior  crural  nerves  seem  to  furnish 
the  best  explanation  of  this. 

Night  Cries. — At  an  early  stage  of  the  affection  the  symptoms 
of  "  night  cries  "  often  appear.  They  occur  in  the  early  part  of  the 
night  usually,  and  may  become  an  annoying  symptom.  After  the 
patient  is  asleep,  and  to  all  appearances  entirely  unconscious,  sleep  will 
be  interrupted  by  a  cry  as  if  of  severe  pain,  followed  by  moaning  or 
crying  for  a  few  seconds,  the  child  being  unconscious  or  only  half- 


FIG.  55. — Severe  Abduction  and  Eversion  in  a  very  Acute  Case. 

conscious  of  the  cause  of  the  pain.  These  do  not  often  occur  when 
the  patient  is  entirely  awake,  and  are  caused  by  the  spasmodic  twitch- 
ing of  the  muscles  abnormally  excitable  from  irritation,  reflex  to  the 
inflammation  of  the  joint.  These  cries  may  be  repeated  fifteen  or 
twenty  times  during  the  night.  They  may  be  entirely  wanting  in  the 
mildest  cases. 

Muscular  fixation  (muscular  spasm)  is  always  present  in  some  de- 
gree, restricting  the  joint's  normal  arc  of  motion.  It  is  due  to  a  reflex 
irritability  of  the  muscles  controlling  the  joint,  which  causes  them  to 
maintain  a  condition  of  tonic  spasm  of  greater  or  less  degree.  It  dis- 
appears under  full  anaesthesia.  Increased  stiffness  appearing  in  the 
course  of  treatment  is  a  sign  of  inefficient  treatment  or  of  increase  of 
the  disease.  This  muscular  rigidity  is  the  most  important  sign  of  the 
disease,  for  not  only  is  it  the  chief  reliance  in  the  matter  of  diagnosis, 
but  it  is  the  cause  of  the  malpositions  of  the  limb,  of  the  wearing  away 
of  the  acetabulum  and  of  the  head  of  the  bone,  and  it  lies  at  the  root 
of  much  of  the  pain.  It  furnishes  the  most  accurate  index  of  the 
progress  of  the  case,  and  improves  or  becomes  worse  as  the  case  be- 
comes better  or  worse.  The  importance  of  the  recognition  and  accu- 
rate study  of  this  symptom  cannot  be  overestimated. 


TUBERCULOUS  DISEASE  OF  THE  HIP  59 

Atrophy. — A  marked  atrophy  of  the  muscles  of  the  thigh,  hip; 
and  leg  is  characteristic.  It  is  supposed  to  be  reflex  to  the  disease  of 
the  joint. 

Atrophy  of  the  muscles  controlling  an  inflamed  joint  begins  early 
and  may  be  very  marked,  even  in  simple  acute  synovitis.  That  this 
is  something  more  than  the  mere  atrophy  of  disuse  is  shown  by  the 
fact  that  it  begins  so  sharply  and  so  early,  that  it  is  greater  in  the 
diseased  limb  than  in  the  well  one  even  when  the  patient  has  been 
in  bed  from  the  first,  and  that  the  muscles,  although  atrophied,  are 
not  soft  and  flabby,  but  tense. 

Diminished  resistance  to  the  passage  of  the  jr-rays  in  the  epiphyses 
of  the  hip,  indicative  of  greater  vascularity,  may  be  seen  in  the  earlier 
stages  of  hip  disease. 

The  obliteration  of  the  fold  of  the  buttock  on  the  affected  side  is  a 
result  partly  of  muscular  atrophy  and  partly  of  the  periarticular  swell- 
ing which  accompanies  the  disease.  It  is  a  common  but  not  a  constant 
symptom  at  the  early  stages  of  the  disease.  It  is  also  partly  due  to 
the  flexed  attitude  of  the  limb,  which  naturally  diminishes  the  prom- 
inence of  the  buttock  on  that  side. 

Malpositions  of  the  Limb. — The  fixation  of  the  diseased  limb  in  a 
distorted  position  is  one  of  the  commonest  incidents  of  the  affection. 
This  is  due  to  the  tonic  muscular  contraction  so  often  alluded  to. 
These  malpositions  may  hold  the  limb  in  flexion,  adduction,  abduction, 
or  eversion,  or  in  any  combination  of  these ;  the  cause  which  deter- 
mines the  kind  of  malposition  in  an  individual  case  cannot  be  formu- 
lated. Flexion  of  the  thigh  is  chiefly  due  to  the  muscular  contraction, 
which  is  constant  in  chronic  disease  of  the  joint,  and  partly  to  an  un- 
conscious effort  on  the  part  of  the  patient  to  assume  a  position  most 
comfortable  for  the  joint  and  most  protected  from  jar.  These  de- 
formities generally  disappear  under  treatment  by  rest  or  traction ;  but 
again,  they  reappear  in  cases  under  treatment  if  treatment  has  not 
succeeded  in  checking  the  progress  of  the  disease.  They  often  accom- 
pany a  sensitive  condition  of  the  joint,  which  may  be  the  precursor  of 
abscess. 

If  the  malposition  is  allowed  to  become  permanent  the  final  result 
can  never  be  so  good  as  when  cicatrization  takes  place  in  a  more  nor- 
mal position.  The  limp  in  ankylosed  limbs  depends  more  upon  the 
amount  of  flexion  and  adduction  than  or  anything  except  perhaps  the 
bone  shortening.  It  is,  therefore,  of  much  importance  to  diminish  in 
all  cases  the  amount  of  malposition  present. 

When  adduction  is  present  in  both  legs,  as  in  double  hip  disease, 


6o 


ORTHOPEDIC  SURGERY 


and  ankylosis  of  both  hips  has  occurred,  cross-legged  progression  may 
be  necessary  on  account  of  the  inability  to  separate  the  legs. 

The  position  in  standing  and  lying  is  modified  by  the  occurrence 


FIG.    56. — Case    Showing    Marked    Flexion 
with  Adduction  of  the  Left  Hip  Joint. 


FIG.   57.— Ankylosis  of  the  Hip  in  a  Position  of 
Flexion    Showing  Lumbar  Lordosis. 


of  these  malpositions;  abduction  or  adduction  causes  tilting  of  the 
pelvis,  and  flexion  causes  a  marked  lordosis  of  the  lumbar  spine  in 
standing  with  the  legs  parallel;  by  standing  with  the  diseased  leg 


TUBERCULOUS  DISEASE  OF  THE  HIP  61 

somewhat  flexed  the  lordosis  can  be  overcome.  The  same  arching  of 
the  lumbar  spine  occurs  when  the  patient  lies  on  a  table  and  the  flexed 
leg  is  brought  down. 

Periarticular  Symptoms. — An  important  sign  is  found  in  the  thick- 
ening over  the  anterior  surface  of  the  joint  when  palpated  in  the  groin 
as  contrasted  with  the  other  side.  An  indefinite  oval  thickened  area 
is  felt  deep  down.  At  other  times  the  thickening  is  most  marked  at 
the  posterior  aspect  of  the  joint,  behind  the  trochanter.  This  sign  is 
an  early  one  and  of  great  value  in  the  early  recognition  of  the  disease. 
A  density  in  the  superficial  tissues  over  a  diseased  hip  which  the  other 
side  does  not  possess  is  often  found  at  a  comparatively  early  stage  of 
the  affection.  Behind  or  in  front  of  the  trochanter  the  deep  tissues  are 
resistant  and  the  fossa  existing  there  is  filled  out,  and  the  great  tro- 
chanter feels  enlarged  and  thicker  than  its  fellow  when  grasped  by 
the  fingers  deeply  pressed  in. 

The  inguinal  glands  of  the  affected  side  are  often  enlarged  and 
they  may  be  so  much  distended  that  they  obstruct  the  venous  return 
and  the  skin  may  be  marbled  with  superficial  veins.  They  are  at 
times  the  seat  of  superficial  abscesses.  A  gland  lying  on  the  iliac 
vessels  is  frequently  found  enlarged  in  hip  disease  and  is  palpated  just 
above  the  ramus  of  the  pubis.  In  very  severe  cases  the  upper  part 
of  the  thigh  and  the  tissues  in  the  vicinity  of  the  hip  may  become 
swollen  generally  from  an  oedema  of  the  periarticular  tissues.  This 
may  disappear  or  become  localized  in  the  formation  of  an  abscess. 

Abscess. — In  a  proportion  of  cases  suppuration  takes  place.  The 
site  and  course  of  the  abscesses  vary  according  to  the  seat  and  size 
of  the  original  focus  of  the  ostitis,  whether  in  the  femur  or  acetabulum. 

Abscesses  may  be  absorbed  or  may  evacuate  themselves  spontane- 
ously either  completely  or  partially,  the  residual  fluid  following  along 
the  course  of  the  sheaths  of  the  muscles  and  the  fasciae,  reappearing 
later  as  secondary  abscesses,  the  same  abscess  causing  five  or  six  fistu- 
lous  openings.  These  openings  discharge  pus  and  serum  for  months 
and  years  in  most  cases.  These  sinuses  after  a  short  time  become 
infected  with  pyogenic  organisms.  With  the  bursting  of  an  abscess 
and  the  discharge  of  any  considerable  quantity  of  pus  the  patient's 
condition  may  show  rapid  improvement,  or,  if  imperfect  drainage 
takes  place,  reaceumulation  of  the  pus  may  occur  and  the  patient's 
condition  may  become  worse. 

When  the  pus  has  left  the  joint  it  generally  burrows  between  the 
thigh  muscles  to  reach  the  skin,  where  it  appears  as  a  swelling  of  vary- 
ing size.  Fluctuation  is  usually  marked.  As  the  abscess  invades  the 


62 


ORTHOPEDIC  SURGERY 


skin  the  latter  becomes  thin  and  red,  and  ulcerates  in  one  or  two 
places,  evacuating  the  abscess.  The  contents  of  the  abscess  may,  how- 
ever, in  a  few  instances  be  absorbed 
even  at  a  stage  when  fluctuation  is 
marked,  and  the  swelling  may  dis- 
appear, perhaps  leaving  a  depres- 
sion beneath  the  skin. 

The  pus  most  commonly  reaches 
the  skin  at  the  anterior  border  of 
the  tensor  vagina?  femoris  muscles; 
it  may,  however,  gravitate  backward 
and  open  back  of  the  great  tro- 
chanter  or  at  the  lower  border  of 
the  glutams  maximus;  it  may  come 
around  to  the  inner  side  of  the  thigh 
and  perhaps  open  in  front  of  the 
adductor  tendons  or  even  discharge 
into  the  rectum;  finally,  it  may  as- 
cend the  sheath  of  the  psoas  muscles 
and  point  above  Poupart's  ligament, 
or  it  may  descend  in  the  thigh  mus- 
cles and  point  in  the  popliteal  space. 
The  seat  of  the  primary  disease  can- 
not be  inferred  from  the  situation  of 
the  abscess. 

Shortening. — The  effect  of  per- 
sistent muscular  spasm  of  muscles 
about  the  hip-joint,  characteristic  of 
hip  disease,  is  to  cro\vd  the  femur 
against  the  acetabulum  and  to  pro- 
duce the  enlargement  of  the  acetabu- 
lum and  the  absorption  of  the  head  of  the  femur,  with  resulting  short- 
ening of  the  limb.  Another  cause  of  shortening  is  to  be  found  in 
the  retarded  growth  of  the  affected  limb. 

General  Condition. — Children  with  hip  disease  are  often  appar- 
ently healthy  at  the  beginning  of  the  affection  and  sometimes  the 
general  condition  continues  good,  but  these  cases  are  exceptional. 
More  often  the  child  is  pale  and  the  appetite  fails  at  times;  there  is 
often  loss  of  flesh ;  in  some  mild  cases  and  in  most  of  the  severe  ones 
decided  constitutional  disturbance  results. 

Double  Hip  Disease. — The  disease  seldom  begins  in  both  hip- 


FIG.  58. — Left  Hip  Disease  with  Abscess 
on   Outer   Side  of  Thigh. 


TUBERCULOUS  DISEASE  OF  THE  HIP 


joints  at  the  same  time,  and  the  second  joint  may  become  inflamed 
while  the  patient  is  under  treatment  in  bed  for  the  first  joint. 

The  course  of  double  hip  disease  would  appear  to  vary  somewhat 
from  that  of  single  hip  disease.  The  amount  of  pain  suffered  in  the 
joint  last  affected  is  usually  less  than  that  of  the  first  joint,  probably 
because  there  is  less  jar  or  motion  when  two  hip-joints  are  affected 
than  when  one  alone  is  attacked. 

Malpositions  are  more  than  usually  troublesome  and  may  be  differ- 
ent in  the  two  hips. 

DIAGNOSIS. 

The  diagnostic  symptoms  in  hip  disease  are  as  follows:  I.  Mus- 
cular spasm  (stiffness  of  the  joint  or  limitation  of  its  motion). 

2.  Lameness.  3.  Attitude  of  the 
limb  in  standing,  walking,  or  ly- 
ing (adduction, flexion, and  abduc- 
tion of  the  limb),  and  shortening. 
4.  Atrophy.  5  Swelling.  These 
symptoms  vary  in  prominence  at 
different  stages  of  the  disease. 

The  early  diagnosis  is  made 
chiefly  by  the  symptom  of  muscu- 
lar rigidity  and  by  palpation  of 
the  joint. 

I.  Muscular  Spasm. — The 
chief  diagnostic  sign  in  hip  dis- 
ease, upon  which  the  main  reli- 
ance must  always  be  placed,  is 
the  presence  of  stiffness  of  the 
joint  or  limitation  of  its  proper 
arc  of  motion  when  the  limb  is 
passively  manipulated.  Except  in 
the  very  earliest  stages  there  can 
be  no  hip  disease  without  a  perceptible  limitation  of  motion,  unless 
the  focus  of  disease  is  remote  from  the  joint.  This  limitation  of 
motion  is  not  the  result  of  adhesions  or  beginning  ankylosis  in  early 
hip  disease,  but  it  is  the  result  of  a  tonic  contraction  of  the  muscles 
controlling  the  joint,  and  disappears  under  anaethesia  in  the  early 
stages  of  the  disease. 

A  comparison  of  the  resistance  of  one  leg  with  that  of  the  other 
will  reveal  abnormal  resistance.  Resistance  to  motion  in  the  direction 


FIG.    59. — Progression    in   a    Case    of    Severe 
Double  Hip  Disease. 


64  ORTHOPEDIC  SURGERY 

of  abduction,  therefore,   is  an  early  test  of   importance.     Extreme 
abduction  and  rotation  of  the  thigh  flexed  at  right  angles  to  the 


FIG.    60. — Method    of    Examining   the    Hip. 


body  are  tests  likely  to  reveal  the  smallest  degree  of  limited  motion. 
In  young  and  frightened  children  the  tests  for  limitation  of  motion 


FIG.  6l.— Method  of  Determining  the  Limitation  of  E> 


at  the  hip-joint  are  best  made  with  the  children  lying  on  the  mother's 
lap  or  leaning  on  the  mother's  shoulder.     In  examining  older  children 


TUBERCULOUS  DISEASE  OF  THE  HIP 


\ 


for  muscular  stiffness,  the  clothes  should  be  removed  and  the  patient 
should  lie  upon  a  hard  surface  rather  than  on  a  bed.  Attempts  to 
move  the  limb  should  be  made  gradually,  gently,  and  persistently — 
rough  force  only  exciting  resistance  and  making  a  delicate  examina- 
tion impossible.  It  is  advisable  first  to  put  the  normal  leg  through 
the  same  manipulations  which  are  to  be  made  on  the  affected  side. 
The  most  convenient  order  of  motion  in  examination  is  first  flexion, 
then  abduction  and  abducting  rotation  with  the  thigh  flexed,  then 
extension.  The  suspected  limb  should  be  held  at  the  ankle  or  knee 
with  one  hand,  while  the  other  hand  will  grasp 
the  pelvis  to  ascertain  when  motion  in  the 
joint  ceases  and  movement  of  the  pelvis  begins. 
Examination  under  anaesthesia  shows  less  than 
the  examination  mentioned,  at  the  early  stage 
of  hip  disease,  as  muscular  spasm,  the  most 
important  diagnostic  sign,  has  been  overcome 
and  is  absent. 

If  the  limb  is  extended  so  that  the  popliteal 
space  be  placed  upon  the  hard  surface  on  which 
the  patient  lies,  normally  there  will  be  no  alter- 
ation of  the  position  of  the  back;  if,  however, 
there  is  a  limitation  in  the  normal  extension 
of  the  limb,  the  back  will  be  arched  up  as  the 
popliteal  space  is  pressed  down.  This  limita- 
tion of  extension  can  also  be  determined  by 
examining  the  patient  lying  upon  the  belly.  If 
one  hand  be  placed  on  the  sacrum  and  the  thighs  be  alternately  raised 
from  the  surface  on  which  the  patient  lies,  a  difference  in  the  amount 
of  motion  at  the  hip  without  moving  the  sacrum  can  easily  be  deter- 
mined. The  limit  to  the  amount  of  abduction  or  adduction  is  deter- 
mined by  placing  one  hand  on  the  anterior  superior  spine  of  the  ilium 
on  the  sound  side,  and  with  the  other  hand  gently  abducting  or  adduct- 
ing  the  suspected  limb;  when  limitation  is  present  the  pelvis,  of  course, 
moves  with  the  diseased  limb.  For  detecting  limitation  of  rotation 
the  thigh  should  be  flexed  to  a  right  angle  and  rotation  tested  in  that 
position.  The  motions  most  often  limited  in  early  hip  disease  are 
abduction,  hyperextension,  and  rotation  when  the  thigh  is  flexed  to 
a  right  angle.  The  loss  of  motion  in  this  group  is  always  sug- 
gestive. 

Careful  inspection  in  the  early  stages  of  hip  disease  during  manipu- 
lation will  sometimes  show  fibrillarv  contraction  of  the  muscles  of  the 


FIG.  62. — Diagram  Showing 
Apparent  Shortening  and 
Lengthening  of  Leg  Due  to 
Tilting  of  the  Pelvis. 


66 


ORTHOPEDIC  SURGERY 


thigh,  especially  the  adductors,  on  sudden  or  unexpected  movement  of 
the  limb. 

In  the  later  stages  of  hip  disease  complete  stiffness  of  the  joint 
may  be  present.     If  this  is  due  to  muscular  spasm  it  disappears,  in 


FIG.   63. — Thomas'   Test   for  the   Estimation   of   Flexion   of  the  Diseased   Leg  in   Hip   Disease. 

a  measure  at  least,  under  complete  anaesthesia.     An  ankylosed  hip- 
joint  is  stiff  under  full  anaesthesia. 

II.  Lameness. — At  the  earliest  stages  the  limping  may  be  inter- 
mittent and  not  constant. 

III.  Attitudes. — Abnormal  positions  of  the  diseased  limb  at  an 
early  stage  of  the  disease  are  caused  by  the  action  of  the  muscles 
holding  the  limb  stiffly  in  a  distorted  position.      Neither  adduction 
nor  abduction  of  the  limb  is  usually  recognized  by  the  patient  as  such, 
but  the  complaint  is  made  that  the  limb  seems  longer  or  shorter  than 
the  other.     The  pelvis  is  tilted,  which  gives  a  practical  lengthening 
of  the  limb  if  abduction  is  present,  and  in  the  same  way  the  limb 
appears  shorter  to  the  patient  if  adducted.     The  tilting  of  the  pelvis 
can  be  recognized  by  drawing  a  line  from  the  anterior  superior  spine 
of  one  side  to  that  of  the  other.     This  should  normally  be  at  right 
angles  with  the  long  axis  of  the  body.     In  this  way  have  arisen  the 
terms  of  apparent  or  practical  shortening  and  lengthening,  which  have 
given  rise  to  some  obscurity,  being  often  confused  with  real  or  bony 
shortening. 

Thomas'  test  for  flexion  is  one  which  is  sometimes  of  use  for  an 
estimation  of  the  amount  of  flexion  deformity.  The  patient  lies  on 
the  back  and  the  well  thigh  is  flexed  on  to  the  abdomen  and  held  there. 
This  places  the  pelvis  in  the  correct  position,  with  the  lumbar  spine  in 


TUBERCULOUS  DISEASE  OF  THE  HIP  67 

contact  with  the  table,  and  the  diseased  thigh  is  by  this  naturally 
thrown  into  a  position  of  flexion  if  such  deformity  exists. 

IV.  Atrophy. — Atrophy  is  a  symptom  of  great  significance.     Its 
absence  in  real  hip  disease  is  most  unusual,  its  presence  suggestive 


FIG.    64. — X-Ray.      Femoral    disease.        Slight    atrophy    of    femur   and    pubic    bone.     Erosion    of 
head  of  femur.      Thickening  of  neck  of  femur. 


but  not  diagnostic,  for  it  exists  in  acute  joint  inflammation  of  any 
type. 

The  measurement  for  atrophy  is  made  with  a  tape  measure  by 
taking  the  circumference  of  both  thighs  and  both  calves  at  the  same 
level  on  each  side.  The  conventional  places  for  such  measurements 
are  at  the  middle  of  the  thigh  and  the  middle  of  the  calf. 

V.  Swelling. — The  existence  of  deep  thickening  over  the  front  of 
the  hip-joint  or  behind  the  trochanter  is  of  importance.  It  is  not 
easily  recognized.  Thickening  of  the  trochanter  major  is  a  diagnostic 
sign  of  assistance. 


68  ORTHOPEDIC  SURGERY 

DIFFERENTIAL    DIAGNOSIS. 

Some  affections  commonly  mistaken   for  tuberculous  hip  disease 
in  practice  deserve  notice. 

1.  Synovitis  of  the  hip,  of  traumatic,  infectious,  or  systemic  ori- 
gin, may  present  the  symptoms  of  hip  disease  and  an  immediate  diag- 
nosis is  not  always  possible,  without  close  observation  of  the  case. 

As  a  rule  hip  disease   is  of   insidious  and  gradual  onset — with 
premonitory  symptoms — while  the  reverse  is  true  of  synovitis. 

2.  Lumbar  Pott's  disease  may  have  for  its  first  symptom  a  limp 
and  a  restriction  of  motion  in  one  leg.     This  is  due  to  the  descent 
of  tuberculous  detritus  in  the  psoas  muscle  or  to  an  irritation  and 
contraction  of  its  fibres.     As  a  rule,  this  limited  motion  is  only  in 
the  direction  of  loss  of  hyperextension,  but  it  may  take  occasionally 
the  form  of  a  general  restriction  of  motion  and  the  joint  may  be 
sensitive  to  manipulation.     The  point  to  be  determined  is  whether 
rigidity  of  the  lumbar  spine  is  present;  if  so,  Pott's  disease  is  to  be 
suspected.     But  sometimes   in  hip   disease  at   a   sensitive  stage  the 
tenderness  of  the  joint  is  so  great  that  on  attempted  flexion  of  the 
spine  the  erector  spime  muscles  are  also  spasmodically  contracted  and 
lead  to  the  appearance  of  rigidity  of  the  lumbar  spine.    The  diagnosis 
may  sometimes  be  a  difficult  one,  and  an  opinion  must  be  withheld 
and  the  case  kept  under  observation  until  characteristic  symptoms  of 
one  affection  or  the  other  develop.     Later  in  the  course  of  lumbar 
Pott's  disease  a  psoas  abscess  may  irritate  the  hip-joint  on  one  or 
both  sides;  this  may  again  simulate  hip  disease.    A  test  of  the  arcs  of 
abduction  and  internal  rotation  (with  the  thigh  at  right  angles  to  the 
bcclv)  cf  the  hip  is  valuable  in  this  connection,  as  these  motions  are 
impaired  or  lost  at  a  comparatively  early  stage  of  hip  disease. 

3.  Chronic  arthritis  deformans,  morbus  coxre  senilis,  is  an  affection 
which  would  be  confounded  with  a  tuberculous  affection  of  the  hip 
if  it  were  not  confined  to  persons  past  middle  life,  when  a  tuberculous 
affection  is  rare. 

4.  Acute  Infectious  Inflammation    (Osteomyelitis). — The   symp- 
toms are  more  acute  than  in  hip  disease,  the  swelling  is  greater,  and 
the  temperature  higher  as  a  rule.     In  young  children  the  diagnosis  is 
often  obscure  until  operation  is  required  by  abscess.     In  Konig's  col- 
lection of  758  cases  of  hip-joint  inflammation  there  were  568  tubercu- 
lous cases  and  110  of  acute  infectious  coxitis. 

5.  Anterior  Poliomyelitis. — At  the  stage  of  onset  of  infantile  par- 
alysis there  may  be  for  a  short  time  marked  pain  and  tenderness,  with 


TUBERCULOUS  DISEASE  OF  THE  HIP  69 

immobility  of  one  limb ;  ordinarily  these  symptoms  are  not  accom- 
panied by  other  symptoms  of  hip  disease,  but  are  accompanied  by 
loss  of  power  of  the  rest  of  the  limb. 

6.  Congenital  Dislocation. — Congenital  dislocation  of  the  hip-joint 
need  not  be  mistaken  for  hip  disease,  as  the  clinical  history  of  the 
former   is  of   continued   limp   since  the   child  commenced   walking. 
There  are  no  symptoms  of  muscular  stiffness  or  limitation  of  motion 
of  the  hip  in  congenital  dislocation;  in  fact,  no  symptoms  of  hip  dis- 
ease except  the  limp  in  gait.     Patients  with  congenital  dislocation, 
however,  at  times  have  slight  attacks  of  synovitis  of  the  hip  due  to 
the  imperfect  mechanism  of  the  joint,  but  these  symptoms  subside  after 
a  short  rest. 

7.  Hysterical  joint  affections  are  to  be  diagnosticated  from  or- 
ganic joint  disease.     In  nervous  children  at  the  prepubertial  period 
a  condition  of  joint  sensitiveness  with  lameness  and  pain  is  observed 
simulating  hip  disease.     The  difference  between  the  functional  affec- 
tion   and    the    organic    is    chiefly    that    the    characteristics    of    the 
former    are    variable    in    their    intensity    and    not    consistent    with 
one  another. 

8.  Coxa  vara,    a  distortion  of  the  neck  of  the  femur,  gives  rise 
to  shortening  and  limping.     The  trochanter  is  higher  than  Nelaton's 
line.     There  is  either  good  motion  at  the  hip-joint  or  the  limitation 
is  in  the  direction  of  abduction,  while  the  flexion  is  free.    The  amount 
of  limitation  of  motion  is1' less  than  would  be  expected  from  the  history 
of  the  case,  which  is  of  long  duration.     The  diagnosis  is  aided  by 
a  skiagram. 

9.  Knee-joint   Disease. — Hip  disease   is  often  diagnosticated  as 
"  knee  trouble,"  so  that  it  seems  worth  while  to  call  attention  to  the 
well-known  fact  that  pain  in  hip  disease  is  in  most  cases  referred  to 
the  inner  side  of  the  knee.     Examination  will  show  which  affection  is 
present. 

10.  Flattening   of   the   Head   of  the    Femur. — A   condition   has 
recently    been     described *     which     simulates     tuberculosis     of     the 
hip.     The  affection  is  characterized  by  lameness  and  some  limita- 
tion   of   motion,    but    pain   is    net    severe   and    the   affection    is    of 
mild     grade,     pursuing     a     slow,     favorable,     and     non-destructive 
course.     Most  of  the  patients  shew  a  negative  Von  Pirquet  reaction. 
The  skiagram  shows  a  flattening  of  the  head  of  the  femur  and  a 
thickening  of  the  neck.     This  condition  has  only  been  very  recently 
identified. 

JLegg:  Boston  Medical  and  Surgical  Journal,  1910,  clxii.,  p.  202. 


;o  ORTHOPEDIC  SURGERY 

ii.  Miscellaneous  Conditions. — PERINEPHRITIS  AND  APPEN- 
DICITIS have  been  mistaken  for  hip  disease.  Such  an  error,  however, 
must  be  rare.  In  the  chronic  forms  of  these  affections  there  may  be 
slight  psoas  contractions  and  the  presence  of  iliac  abscesses.  In  these 
affections  the  limitation  to  motion  of  the  thigh  at  the  hip-joint  is  not 


FIG.  65.— X-Ray  Illustrating  Flattening  of  the  Head  and  Thickening  of  Neck  of  each  Ftmur. 

general  nor  does  it  affect  abduction,  but  it  is  most  marked  in  the 
direction  of  limitation  of  extension. 

PERIARTICULAR  DISEASE,  which  has  not  yet  attacked  the  joint  or 
the  epiphyses  of  the  joint,  is  recognized  with  difficulty.  Under  the 
head  of  periarticular  disease  may  be  included  inflammation  of  bursse 
and  lymphatic  glands,  psoas  abscess,  or  psoas  muscular  spasm  from 
caries  of  the  lumbar  spine. 

SARCOMA  of  the  hip  may  be  mistaken  for  hip  disease  or  hip  dis- 
ease for  sarcoma.  The  .r-ray  may  give  assistance  in  the  diagnosis 
and  a  piece  of  the  growth  should,  of  course,  be  removed  for  exam- 
ination. 

SEPARATION  OF  THE  EPIPHYSIS  OF  THE  FEMUR. — Separation  of 
the  epiphysis  or  fracture  of  the  neck  of  the  femur,  with  the  resulting 
distortion,  which  may  be  termed  traumatic  coxa  vara,  can  be  distin- 


TUBERCULOUS  DISEASE  OF  THE  HIP  71 

guished  from  hip  disease  by  the  history  aided  by  an  ,r-ray  examina- 
tion. In  acute  rickets — in  overgrown  children — a  condition,  which 
may  be  considered  a  congestion  of  the  epiphysis  of  the  hip,  may 
present  some  symptom  resembling  hip  disease — limp  and  sensitive- 
ness. The  condition  is,  however,  a  temporary  one. 

PROGNOSIS. 

Under  favorable  surroundings  the  disease  is  one  which  tends  to 
recovery  in  a  majority  of  cases  with  more  or  less  deformity.  It  is 
the  duty  of  the  surgeon  to  see  that  the  chances  of  recovery  are  as 
favorable  as  possible,  and  when  recovery  occurs  that  it  shall  result 
with  the  least  deformity  and  the  most  useful  limb  possible. 

Mortality. — The  rate  of  the  mortality  due  to  the  disease  in  hip 
disease  is  greater  among  the  poorly  nurtured  hospital  cases  than 
where  after-treatment  can  be  carefully  looked  after.  The  rate  of 
mortality  in  neglected  and  untreated  cases  is  high — especially  of  the 
class  placed  in  hospitals;  with  proper  treatment  the  percentage  of 
mortality  has  been  much  reduced. 

Causes  of  Death. — Death  may  occur  from  ( i )  the  generalization 
of  tuberculosis  in  the  form  of  phthisis,  tuberculous  meningitis,  and 
general  tuberculosis;  (2)  from  amyloid  degeneration  of  the  viscera; 
(3)  from  exhaustion;  (4)  from  intercurrent  disease;  (5)  from  septi- 
caemia and  exhaustion  after  suppuration. 

Functional  Results. — Spontaneous  cure  may  result  in  hip  disease, 
but  as  a  rule  with  little  motion  and  with  marked  deformity. 

Recovery  with  motion  after  extensive  tuberculous  hip  disease  is 
rare,  but  occurs  even  in  hospital  cases.  From  this  condition  to  com- 
plete loss  of  motion  the  cases  range  according  to  the  thoroughness  of 
treatment,  the  severity  of  the  disease  in  the  individual  case,  and  the 
resistance  of  the  child.  The  earlier  that  treatment  is  begun  the  better 
the  outlook. 

Length  of  Time  for  Treatment. — The  early  discontinuance  of 
treatment  may  be  a  serious  mistake,  as  relapses  occur  in  some  in- 
stances when  the  joint  has  apparently  fully  recovered.  Treatment 
should  be  continued  not  only  until  the  bone  has  become  not  only 
sufficiently  strong  to  bear  weight  without  pain  and  muscular  spasm, 
but  to  withstand  the  bruises  of  falls  or  violent  activity.  The  length 
of  time  for  careful  observation  to  insure  against  relapses  is  long. 
Under  careful  treatment  recovery  should  take  place  without  distor- 
tion. To  secure  this,  mechanical  treatment  is  needed  for  a  long 
period  after  the  cessation  of  active  symptoms. 


72  ORTHOPEDIC  SURGERY 

Actual  shortening  due  to  arrest  of  growth  of  the  limb  is  beyond 
the  control  of  the  surgeon;  but,  shortening  from  subluxation  or 
dislocation  of  the  head  of  the  femur  or  enlargement  of  the  ace- 
tabulum  may  be  said  to  be  preventable  under  proper  treatment. 

TREATMENT. 

Measures  of  advantage  in  combating  tuberculosis  in  general, 
fresh  air  and  the  improvement  in  metabolism  are  of  importance  in 
the  treatment  of  tuberculous  ostitis  of  the  hip,  as  of  other  joints — 
but  the  hip-joint  differs  from  the  other  joints  anatomically  in  that 
it  is  deep-set  and  is  surrounded  by  strong  muscles.  These,  in  case 
of  acute  inflammation  of  the  joint,  develop  a  condition  of  exag- 
gerated irritability  analogous  to  the  blepharospasm  in  ulceration  of 


FIG.  66. — Application  of  Plaster  Spica  Hip  Bandage. 

the  cornea.     This  condition  needs  surgical  consideration,  and  unless 
checked  it  will  develop  deformity  and  destruction  of  the  joint. 

It  is  necessary  in  the  acute  stages  to  fix  the  joint  to  check  or  heal 
existing  ostitis,  and  it  is  difficult  to  do  so,  as  it  is  not  easy  to  secure 
firmly  the  upper  portion  of  the  joint,  viz.,  the  pelvis,  which,  owing  to 
the  mobility  of  the  lumbar  vertebra,  is  not  secured  by  fixing  the  trunk; 
but  unless  reasonable  fixation  is  secured  the  muscular  spasm  of  the 
joint  muscles  will  be  increased  by  repeated  jar.  These  muscles  are  in 
hip-joint  inflammation  in  a  state  of  reflex  irritability  or  of  tonic  spasm, 
and  either  crowd  the  head  of  the  femur  against  the  acetabulum  by  a 
continued  muscular  contraction  or  inflict  upon  the  joint  the  injury  of 


TUBERCULOUS  DISEASE  OF  THE  HIP 


73 


a  sudden  muscular  contraction  of  all  the  muscles  around  the  hip. 
Adults  who  have  experienced  these  attacks  of  muscular  spasm  liken 
the  sensation  to  that  of  a  blow  of  a  sledge-hammer  upon  the  hip. 

The  indications  for  surgical  treatment  in  hip  disease  consist  of  the 
employment  of  such  measures  as  will  check  and  promote  the  healing 
cf  the  local  lesion,  correct  and  prevent  the  development  of  deformity, 
and  secure  the  best  possible  ultimate  functional  result. 

As  far  as  is  possible  without  injury  to  the  diseased  condition  of 


FIG.  67.-  Plaster  Spica  Hip  Bandage.    Note  scoring  in  over  crest  of  ilia. 

the  joint,  the  treatment  should  be  ambulatory,  as  confinement  to  the 
bed,  unless  necessary  to  check  pain  or  conserve  strength,  injures  the 
general  condition. 

Plaster-of-Paris  Spica. — The  plaster-of-Paris  bandage  spica  fur- 
nishes a  ready  means  of  serviceable  fixation  of  the  hip.     The  patient, 


74 


ORTHOPEDIC  SURGERY 


anaesthetized  if  necessary,  is  placed  upon  a  spica  stand  and  a  mod- 
erate amount  of  traction  is  applied  to  the  limb,  which  should  be 
abducted  from  20°  or  30".  The  skin  in  the  perineum  and  over  regions 
of  bone  prominence  is  to  be  protected  by  wadding  and  a  smooth 
bandage  applied  in  the  acutest  stage.  It  is  advisable  to  include  the 


FIG.  68.— Abduction  Splint  Applied. 

well  hip  temporarily,  removing  this  portion  of  the  bandage  when  the 
symptoms  of  acute  sensitiveness,  if  present,  subside.  The  bandage 
should  reach  well  up  on  the  thorax  and  include  the  foot,  if  an  ade- 
quate amount  of  joint  fixation  is  desired.  Locomotion  is  possible 
with  crutches  if  the  foot  on  the  well  side  is  raised  by  means  of  a  raised 


TUBERCULOUS  DISEASE  OF  THE  HIP 


75 


sole.  A  short  plaster  spica  bandage  does  not  fix  the  hip- joint,  and 
though  it  checks,  does  not  prevent  the  development  of  deformity.  An 
effective  plaster  spica  or  its  substitutes,  stiffened  leather  or  celluloid 
paste  appliances  moulded  from  plaster  casts,  if  efficient,  are  cum- 
bersome. They  are  irksome  to  large  patients  and  burdensome  to  the 
very  small,  and  lighter  and  equally  efficient  appliances  are  desirable. 

Traction  and  Abduction  Splint. 
— Various  forms  of  apparatus  have 
been  devised  for  the  purpose  of 
fixing  the  hip  by  means  of  a  trac- 
tion force  and  at  the  same  time  over- 
coming the  chronic  muscular  spasm 
at  the  hip.  The  one  here  described 
has  demonstrated  its  efficiency  for 
several  years  at  the  Boston  Chil- 
dren's Hospital.  It  consists  of  two 
steel  rods,  longer  than  the  affected 
limb,  connected  below  by  a  flat  bar 
furnished  with  a  small  windlass 
attachment  to  furnish  traction,  and 
above  by  a  ring  open  in  front, 
obliquely  placed  upon  the  reds  so  as 
to  fit  the  buttock  from  the  tuber 
ischii  to  above  the  great  trcchanter, 
as  in  the  well-known  Thomas  knee 
splint.  Attached  to  the  ring  near 
the  top  of  the  inner  rod  is  welded 
a  bent  steel  rod,  which  passes  above 
the  symphysis  pubis  and  under  the 
perineum  of  the  well  side,  and 
should  be  long  enough  so  that  the 
end  should  net  press  into  the  but- 
tock when  the  patient  is  seated. 
The  upper  rings  are  padded  and 
covered  with  leather,  and  if  prop- 
erly shaped  are  not  soiled  by  the  feces  or  urine.  Traction  is  fur- 
nished by  means  of  adhesive  plaster  straps  applied  to  the  limb 
attached  to  webbing  straps  secured  to  the  windlass.  Circular  leather 
straps  steady  the  limb.  It  will  be  found  that  more  fixation  of  the 
hip-joint  is  furnished  than  by  the  ordinary  plaster-of-Paris  spica 
bandage;  and  while  the  appliance  is  much  less  cumbersome,  the  limb 


FIG.  69. — Abduction  Splint  for  Traction  in 
Hip  Disease. 


ORTHOPEDIC  SURGERY 


is  held  well  abducted  and  the  tendency  to  the  deformity  of  adduction 
checked.  The  appliance  is  light,  not  expensive,  and  requires  no  more 
skill  in  adjustment  than  is  easily  acquired  by  any  one  familiar  with 


FIG.   70.— Traction  Hip   Splint,  High   Sole  and  Crutches     FIG.   71.— Thomas  Hip  Splint  Covered 
Applied.  and  Provided  with  Straps. 

the  use  of  appliances.  Locomotion  is  made  possible  if  a  raised  sole 
is  applied  to  the  well  foot,  but  crutches  are  advisable  in  the  more 
acute  stage. 

Recumbent  Treatment. — Tn    the   most   acute   stage   a   convenient 
method  of  treatment  will  be  furnished  by  the  use  of  bed  traction  and 


TUBERCULOUS  DISEASE  OF  THE  HIP 


77 


the  bed  frame.  The  child  is  placed  upon  the  back  upon  a  frame, 
and  the  shoulders,  pelvis,  and  unaffected  leg  are  secured  by  means 
of  straps.  Traction  is  then  applied  to  the  length  of  the  leg  by  a  pulley 
attached  to  the  foot  of  the  bed.  This  pulley  is  arranged  in  such  a 
way  that  it  pulls  upon  the  diseased  leg  in  the  line  in  which  it  is  held 
when  the  pelvis  is  placed  square  upon  the  frame.  If  flexion  is  present 
the  pulley  is  elevated,  and  if  adduction  or  abduction  is  present  the 
leg  is  pulled  in  or  out.  If  the  leg  is  pulled  in  a  position  of  flexion,  it 
is  held  in  position  by  an  inclined  plane  or  by  a  firm  pad  placed  under 
it.  The  amount  of  traction  force  to  be  used  is  a  question  of  judgment 


FIG.  72. — Traction  by  Inclined  Plane. 

in  each  case,  but  as  much  weight  should  be  applied  as  can  be  borne 
without  discomfort  to  the  patient.  The  foot  of  the  bed  should  be 
raised  to  furnish  counter-traction,  or  an  attachment  can  be  made 
allowing  the  weight  and  pulley  to  play  on  an  attachment  to  the  bed 
frame.  In  cases  in  which  traction  efficiently  used  dees  not  afford 
relief,  lateral  traction  may  be  added.  This  is  furnished  by  means  of 
a  cloth  band  passing  around  the  inner  side  of  the  upper  part  of  the 
thigh  which  runs  straight  cut,  and  is  attached  to  a  weight  hanging 
over  the  edge  of  the  bed.  Resistance  to  this  pull  is  furnished  by 
another  cloth  band  running  around  the  ilium  on  the  diseased  side, 
passing  around  the  patient,  and  over  the  other  side  of  the  bed  to 
be  attached  to  another  weight.  The  amount  of  these  weights  is  to  be 
determined  by  the  comfort  of  the  patient.  "When  the  acute  stage  has 
subsided  and  deformities  have  been  corrected  the  ambulatory  treat- 
ment already  described  can  be  employed. 

Traction  Straps. — The  readiest  way  to  obtain  the  hold  upon  the 


78  ORTHOPEDIC  SURGERY 

limb  for  an  extending  force  is  by  means  of  adhesive  plaster  applied 
as  indicated  in  the  diagram.  It  should  be  applied  firmly  to  the  thigh 
above  the  knee.  If  applied  to  the  leg  alone,  traction  falls  upcn  the 
knee  and  may  cause  relaxation  of  the  ligaments  of  that  joint.  Efficient 
plaster  should  be  used,  of  a  kind  that  will  adhere  readily  without 


FIG.  73. — Long  Traction  Hip  Splint. 
(See  Figs.  119  and  122.) 


FIG.    74. — Side    View    of    the    Long 
Traction  Appliance. 


being  heated.  The  plasters  should  be  changed  every  three  or  four 
weeks,  or  oftener  if  they  cause  irritation.  They  can  readily  be  re- 
moved, if  the  skin  and  plasters  be  thoroughly  moistened  with  benzin 
or  ether.  If  any  portion  of  the  limb  is  chafed  by  the  plaster,  it  may 
be  protected  by  means  of  a  cloth  covered  with  ointment  placed  over 
the  part,  and  the  plaster  be  applied  over  the  cloth  and  the  whole  limb; 
of  if  the  chafing  is  extensive,  the  whole  limb  can  be  covered  with  zinc 
ointment  and  protected  by  a  smooth  bandage,  and  the  plaster  put  on 
over  the  bandaged  limb.  This  will  require  frequent  renewal,  but  will 
answer  temporarily.  A  bandage  applied  over  the  plaster  impedes 
the  circulation  and  increases  the  danger  of  eczema  or  chafing.  If  a 


TUBERCULOUS  DISEASE  OF  THE  HIP 


79 


bandage  is  applied  over  the  plaster  and  worn  for  a  few  hours  after 
it  is  first  put  on,  sufficient  adhesion  of  the  plaster  will  be  secured  if 


FIG.   75. — Lateral  Traction  in  Hip  Disease. 


proper  plaster  is  used.  In  certain  cases  an  obstinate  eczema  is  occa- 
sioned by  the  adhesive  plaster,  and  it  is  necessary  to  have  recourse  to 
some  other  means  of  extension.  Substitutes  for  plaster  are  to  be 


FIG.    76. — Side  View  of  Thomas   Splint  Applied  but  not  Bandaged.     (Bennie.) 

found,  gaiters  applied  to  the  ankle  or  straps  above  the  knee.     These, 
however,  will  slip  if  more  than  a  slight  traction  force  be  applied, 


8o 


ORTHOPEDIC  SURGERY 


and  are  not  as  a  rule  satisfactory.  Another  form  of  traction  strap 
can  be  made  in  the  following  way :  Cloth  is  cut  to  fit  the  thigh  and 
leg  accurately;  webbing  straps  and  buckles  or  lacings  are  attached, 
which  when  tightened  give  a  hold  upon  the  thigh  above  the  knee. 
If  straps  are  sewed  to  this  leather  or  cloth  legging,  they  can  be  made 


FIG.    77. — Crutch    Tip    Convalescent    Hip 
Splint,  Applied. 


FIG.       78. — Jointed       Convalescent 
Splint,  Applied. 


Hip 


to   furnish   fairly  efficient  traction:  but  they  are  likely  to  slip,  and 
are  inferior  to  the  simple  adhesive  plaster  as  a  means  of  traction. 

Crutches. — \Yith  an  efficient  traction  splint  thoroughly  applied,  a 
sufficient  amount  of  restraint  of  motion  at  the  hip-joint  can  be  fur- 
nished to  enable  a  patient  not  in  the  acute  stage  of  the  disease  to 
move  about  with  the  aid  of  crutches,  the  well  limb  being  elevated  by 


TUBERCULOUS  DISEASE  OF  THE  HIP  Si 

a  raised  shoe.  In  cases  with  any  tendency  to  acuteness,  however, 
thorough  traction  is  essential,  and  walking  on  a  traction  splint  with- 
out crutches  is  liable  to  cause  perineal  chafing  and  less  efficient  trac- 
tion, as  at  each  step  on  the  splint  the  traction  force  is  somewhat 
diminished,  on  account  of  the  yielding  of  the  perineal  straps.  In 
cases  in  which  convalescence  has  been  established,  crutches  may  be 
dispensed  with  and  less  traction  exerted. 

Protection. — During  the  stage  of  convalescence  and  in  the  subacute 
stage  the  exercise  of  care  and  judgment  is  especially  needed  in  the 
treatment  of  a  case  of  hip  disease.  The  bone  has  healed  sufficiently 
to  permit  weight-bearing  without  discomfort,  and  the  natural  indica- 
tion is  to  discard  all  bandages  or  apparatus. 

But  unless  the  bone  tissue  is  completely  healed  it  is  bruised  under 
repeated  jar  incident  to  slight  falls  or  constant  slight  injuries,  and 
enough  irritation  results  to  cause  the  development  gradually  of  de- 
formity. At  this  stage  the  joint  needs  protection  though  it  does  not 
need  fixation.  Weight-bearing  is  to  be  gradually  and  tentatively  per- 
mitted, judging  each  case  according  to  its  condition. 

The  simplest  way  to  protect  a  joint  is  with  the  use  of  crutches,  the 
sound  limb  being  raised  by  means  of  a  patten  on  the  shoe  of  the  sound 
limb,  enabling  the  affected  limb  to  swing  free  of  the  floor;  but  as 
children,  if  able  to  use  their  limbs  without  pain,  discard  crutches 
freely,  and  if  there  is  no  protection,  no  check  is  furnished  on  the 
tendency  of  the  limb  to  flex  and  adduct,  which  tendency  persists 
as  long  as  joint  tenderness,  irritability,  or  congestion  remains.  For 
this  reason,  what  may  be  termed  perineal  or  ischiatic  crutches 
are  of  service,  permitting  locomotion  but  protecting  the  joint  from 
the  injury  caused  by  the  body  weight  falling  on  the  joint  at  every 
step. 

A  serviceable  protection  splint  is  furnished  by  removing  from  the 
traction  splint  the  traction  attachment,  leaving  the  perineal  ring, 
uprights,  and  foot  cross  bar.  The  apparatus  should  be  longer  than 
the  limb,  so  that  the  body  weight  falls  in  part  or  in  whole  on  the 
perineal  ring  and  not  on  the  joint.  The  abduction  attachment  can 
be  removed  or  not,  according  to  the  presence  or  absence  of  a  tend- 
ency to  adduction.  Flexion  is  checked  by  a  strap  securing  the  knee 
to  the  splint. 

It  is  not  necessary  in  young  children  that  the  protection  splint 
be  jointed  at  the  knee,  although  this  is  of  advantage  in  adults.  As 
the  patient's  condition  improves,  the  splint  can  be  shortened  and  jar 
gradually  be  allowed  to  come  upon  the  limb. 


82  ORTHOPEDIC  SURGERY 

Relapses. — Hip  disease  is  not  ended  when  the  acute  symptoms 
have  subsided;  a  process  which  requires  so  long  a  time  for  its  devel- 
opment requires  also  much  time  fcr  its  disappearance;  but  after  the 
bone  is  thoroughly  cicatrized  and  the  patient  has  developed  an  im- 
munity to  tuberculosis,  true  relapses  do  not  occur  in  a  healed  joint. 
Patients,  however,  cured  with  flexed  or  adducted  hips  may  suffer  in 
later  life  from  painful  attacks  from  overstrain  of  the  ligamentous 
attachments  of  the  joints;  this  is  especially  true  if  the  patient  becomes 
heavy  or  muscularly  weak.  This  painful  stage  yields  to  the  treatment 
by  rest  or  protection  for  a  short  time.  If,  however,  much  deformity 
persists,  correction  of  the  deformity  is  necessary. 

THE  TREATMENT  OF  COMPLICATIONS. 

Abscess. — Abscesses  due  to  hip  disease  may  in  the  early  stages  be 
absorbed  in  seme  cases  under  treatment. 

Incision  under  strict  aseptic  precautions  is  to  be  advised  in  all 
cases  in  which  absorption  seems  unlikely;  exploration  of  the  joint 
cavity  should  be  made  if  the  abscess  communicates  freely  with  it,  and 
possibly  softened  bone  may  be  scraped  out.  The  abscess  cavity  should 
be  examined  for  pockets,  wiped  out  with  dry  gauze,  and  drained. 
Sinuses  may  persist  for  some  time. 

Where  an  abscess  is  well  localized  and  there  are  no  constitutional 
disturbances  it  may  be  treated  expectantly  and  allowed  to  evacuate 
itself  without  incision.  If  this  is  done  the  skin  before  and  after  the 
evacuation  should  be  protected  by  antiseptic  ointment  and  antiseptic 
dressing.  An  incision  is  made  if  the  abscess  is  situated  where  it 
cannot  evacuate  itself  completely,  leaving  a  residue. 

Night  Cries. — This  troublesome  complication  usually  disappears 
after  the  establishment  of  thorough  treatment.  It  is  indicative  of 
an  active  condition  of  the  process  of  epiphyseal  ostitis  and  is  as  a 
rule  indicative  of  imperfect  fixation  of  the  limb.  In  some  instances 
it  persists  for  several  weeks  under  treatment.  In  such  cases  an  abscess 
is  usually  developed  later. 

Deformity. — The  deformities  occurring  are  flexion,  abduction,  and 
adduction,  or  any  combination  of  these. 

CORRECTION  BY  THE  TRACTION  SPLINT. — Slight  cases  of  deform- 
ity can  be  corrected  by  the  use  of  traction  splints,  which  allow  the 
patient  to  go  about  with  the  aid  of  crutches.  The  traction  splint 
antagonizes  adduction  of  the  limb  by  its  pressure  on  a  counter-point 
in  the  perineum. 


TUBERCULOUS  DISEASE  OF  THE  HIP  83 

CORRECTION  BY  RECUMBENCY. — In  the  severer  cases  rest  in  bed 
hastens  correction.  If  the  patient  is  allowed  to  roll  about  in  bed,  or 
sit  up,  or  hold  the  limb  flexed  at  the  knee,  it  is  manifest  that  no  proper 
traction  force  is  being  used.  It  is  obvious,  therefore,  that  the  patient 
should  be  fastened  to  a  bed  frame  and  traction  made  in  the  line  of 
deformity.  As  the  malposition  of  the  leg  diminishes  under  treatment, 
the  line  of  the  pull  is  made  gradually  more  in  the  long  axis  of  the 
body.  The  ill  effect  of  a  pulling  force  not  in  the  line  of  the  deformity 
in  the  acute  stages  of  hip  disease  is  evident.  If  an  attempt  is  made 
to  force  the  limb  down  in  a  case  of  flexion,  and  a  pull  be  made  in 
the  line  of  the  axis  of  the  body,  the  head  of  the  femur  is  crowded 
upward  to  the  anterior  edge  of  the  acetabulum  by  the  force  applied 
at  the  end  of  the  lever,  viz.,  the  femur,  the  contraction  of  the  flexor 
muscles  (holding  the  limb  flexed)  furnishing  the  fulcrum.  In  milder 
stages  of  the  disease  this  is  not  so  important  as  in  the  acuter  stages, 
but  it  is  a  mechanical  error  in  any  stage  to  attempt  traction  except  in 
the  line  of  the  deformity.  This  error  is  often  the  occasion  of  increas- 
ing the  pain  and  sensitiveness  in  cases  of  hip  disease. 

CORRECTION  UNDER  AN  ANAESTHETIC. — In  cases  of  resistant  de- 
formity treatment  by  traction  is  tedious  and  in  the  more  obstinate 
cases  ineffectual.  In  cases  of  this  character  the  use  of  judicious  force 
under  an  anaesthetic  is  advisable.  Care  must  be  exercised  not  to 
inflict  trauma  upon  tuberculous  bone,  but  where  resistance  is  firm, 
cicatrization  of  the  diseased  area  can  be  supposed  to  have  taken  place, 
and  often  but  little  force  is  necessary  to  secure  correction.  Division 
of  the  contracted  fascia  lata  and  adductor  muscles  will  be  of  assist- 
ance in  some  instances.  After  correction  the  limb  should  be  fixed 
in  a  plaster-of-Paris  spica  bandage,  in  a  corrected  position  with  slight 
abduction.  When  firm  ankylosis  is  present  manual  correction  will 
not  be  sufficient  and  recourse  to  osteotomy  will  be  needed. 

CORRECTION  BY  OSTEOTOMY. — The  operation  in  common  use  was 
devised  by  Gant;  in  this  the  femur  is  divided  below  the  trochanter 
minor.  The  anatomical  reasons  which  he  gave  for  this  step  were 
that  the  resistance  of  the  psoas  and  iliacus  muscles  was  set  free  and 
that  a  return  of  the  flexion  was  not  therefore  to  be  expected,  as  when 
the  bone  was  divided  above  the  attachment  of  these  muscles.  He 
also  called  attention  to  the  fact  that  in  operating  for  ankylosis,  after 
hip  disease,  it  was  desirable,  if  possible,  to  make  the  section  through 
healthy  bone  and  as  far  as  possible  from  the  original  seat  of  the 
disease;  in  this  way  diminishing  the  liabilty  of  rekindling  the  old 
joint  inflammation. 


84  ORTHOPEDIC  SURGERY 

After  the  bone  is  broken,  in  most  cases  the  flexed  leg  can  be  ex- 
tended and  the  aclductecl  one  brought  straight.  If  the  osteotomy  has 
been  efficiently  performed  little  force  is  needed  to  correct  the  deform- 
ity. There  is  little  bleeding  and  a  small  skin  wound,  unless  it  is 
necessary,  as  sometimes  happens,  to  make  a  cut  in  the  anterior  sur- 
face of  the  upper  thigh,  to  divide  bands  of  contracted  fascia  which 


FIG.   79. — Adduction    Deformity    Resulting    from         FIG.      80.- — Adduction      Deformity      Resulting 
Hip  Disease  before  Correction.     (C.  F.  Painter.)  from  Hip  Disease  after  Correction.      (C.  F. 

Painter.)     Same  patient  as  Fig.  79- 

prevent  full  extension  of  the  thigh;  but  under  ordinary  circumstances 
this  is  unnecessary  if  a  thorough  stretching  is  given  to  the  limb  after 
the  division  of  the  bones.  The  patient  should  then  be  fixed  in  a 
carefully  applied  plaster  spica  bandage,  which  should  secure  the  hip 
firmly  in  the  abducted  position.  The  anterior  spines,  the  patella, 
and  the  vertebral  spines  should  be  well  protected  by  padding  to  pre- 
vent sloughs. 

If  it  is  desired  to  compensate  for  bone  shortening  it  can  be  done 


TUBERCULOUS  DISEASE  OF  THE  HIP  85 

by  putting  up  the  shortened  leg  in  an  abducted  position.  The  latter 
will  be  found  of  assistance  where  the  shortening  is  great,  as  the 
resulting  tilting  of  the  pelvis  adds  to  the  practical  length  of  the  limb. 
The  risks  attending  the  operation  are  slight. 

After  the  cessation  of  bed-treatment,  fixation  in  a  plaster-of- 
Paris  spica  should  be  continued  for  at  least  six  weeks  more.  If  fixa- 
tion in  the  improved  position  is  abandoned  too  early  the  deformity 
may  recur. 

The  ultimate  functional  results  following  the  operation  are  ex- 


FIG.  81.  FIG.  82. 

FIG.  81. — Specimen    from    Excision    of    Hip    when    Traction    has    not   been    Employed.      Severity 

and  duration  of  disease  similar  to  that  of  case  in  Fig.  82. 

FIG.  82. — Specimen    from    Excision    of    Hip    Treated    by    Efficient    Traction    for    Three    Years. 
Operation   done  because   of  failure  in   general   condition. 

cellent.  Although  there  may  be  no  motion  at  the  hip- joint,  the 
lumbar  vertebrae  are  usually  more  movable  than  normal.  The  opera- 
tion is  indicated  in  all  cases  of  severe  deformity  in  which  the  distor- 
tion interferes  seriously  with  locomotion,  but  should  not  be  per- 
formed except  upon  patients  in  excellent  condition,  as  the  possibility 
of  delayed  union  should  not  be  disregarded.  The  operation  should 
be  postponed  in  rapidly  growing  adolescents. 

Shortening  of  the  Limb. — Shortening  of  the  limb  after  hip- 
joint  disease  occurs  in  a  certain  number  of  cases  from  arrest 
of  growth.  Prevention  of  the  development  of  the  disease  and 
such  use  of  the  limb  as  is  compatible  with  the  safety  of  the  joint, 
inducing  proper  circulation  in  the  limb,  may  be  regarded  as  the  only 
means  at  our  command,  as  operative  lengthening  of  bone,  successfully 
done  upon  animals,  is  at  present  experimental  surgery.  It  may  be 


86 


ORTHOPEDIC  SURGERY 


hoped,  however,  that  the  method  may  be  successfully  developed.  The 
shortening  due  to  subluxation  is  in  a  large  measure  prevented  by 
efficient  treatment. 

Patients  with  much  shortening  of  the  diseased  leg  vary  a  great 
deal  in  the  relief  afforded  by  a  high  shoe;   sometimes  they  find  it 


FIG.  83. — Double  Thomas  Hip  Splint,  Applied. 

of  the  greatest  possible  benefit,  while  at  other  times  it  is  a  constant 
annoyance.  The  shoe  can  be  raised  by  a  cork  sole,  or  more  cheaply 
by  an  iron  or  wooden  patten,  or  by  an  arrangement  in  which  the 

foot,  like  the  stump  of  an  amputated  limb, 
fits  into  the  socket  of  a  specially  constructed 
elongated  boot,  which  conceals  the  short- 
ening. 

Double  Hip  Disease. — During  the  acute 
stage  of  the  disease  recumbency  on  a  bed- 
frame  and  efficient  traction  by  weight  and 
pulley  or  by  two  traction  splints  is  the  best 
treatment.  After  the  stage  of  spasm  has 
passed,  the  patient  can  be  carried  about  in 
a  double  Thomas  splint  and  when  con- 
valescence is  established,  locomotion  with 
traction  or  protection  splints  and  crutches 
is  possible.  The  chief  difficulty  in  treating 
double  hip  disease  is  in  the  prevention  of 
deformity,  not  so  much  during  the  active 
stage  of  the  disease,  but  after  the  con- 
valescence has  been  established. 

Defcrmitv   will    probablv   not   occur   if 

FIG.  84— Thomas  Hip  Splint.  .  "  ,1  ~    .         . 

Double    (Ridion)  patients  are  kept  recumbent  for  a  sufficiently 


TUBERCULOUS  DISEASE  OF  THE  HIP  87 

long  time  to  establish  a  perfect  cure.  If,  however,  they  are  allowed 
to  walk  or  move  too  soon,  before  the  joints  are  thoroughly  strong, 
weight  must  necessarily  fall  upon  the  affected  limbs  in  walking.  If 
these  are  not  sufficiently  recovered  to  sustain  the  weight,  deformity 
may  ensue.  The  use  of  double  protection  splints  is  indicated  at  this 
stage.  Even  with  very  little  motion  in  either  hip- joint  locomotion  is 
often  possible,  although  the  gait  is  necessarily  restricted. 

Ankylosis  of  the  Hip. — A  firmly  ankylosed  hip  with  the  limb 
in  a  suitable  position  gives  comparatively  little  discomfort,  but  when 
both  hips  are  ankylosed  a  formidable  disability  exists.  Attempts  to 
correct  this  can  be  made,  with  a  prospect  of  success  proportionate  to 
the  amount  of  bone  destruction  from  the  previous  disease.  The  joint 
is  cut  down  upon  the  head  freed  by  dissection,  chisel  or  saw,  and 
covered  by  several  layers  of  Cargile  animal  membrane,  stretched  well 
around  it,  or  by  a  flap  of  fat,  muscle  or  fascia.  The  wound  is  then 
closed  and  the  limb  secured  in  a  slightly  abducted  position  by  means 
of  a  plaster  spica  bandage. 


OPERATIVE   TREATMENT. 

Curetting  and  Drainage  of  Tuberculous  Areas  in  Hip  Disease. — 
In  cases  of  tuberculous  ostitis  of  the  hip,  when  the  process  is  limited 
to  sharply  defined  foci  surrounded  by  firm  bone,  the  condition  may  be 
said  to  resemble  that  presented  by  an  abscess,  and  drainage  of  such 
a  focus  is  desirable.  This  can  be  accomplished  by  tunnelling  through 
the  healthy  bone  until  the  diseased  focus  is  reached. 

The  operation  is  performed  by  exposing  the  part  of  the  bone  in 
which  the  focus  has  been  located  and  removing  it  by  thorough  curet- 
ting. The  cavity  is  then  carefully  dried  and  wiped  out  with  strong 
carbolic  acid  and  alcohol  or  a  2.5-per-cent  solution  of  formalin,  and 
the  wound  closed,  with  the  exception  of  a  temporary  gauze  wick. 
The  operation  should  be  performed  with  as  little  unnecessary  trau- 
matism  to  the  joint  as  possible.  The  operation  is  followed  by  traction 
in  the  recumbent  position. 

Excision  is  rarely  justified  when  conservative  treatment  can 
be  carried  out  for  a  sufficient  time  and  with  thoroughness.  The 
removal  of  the  head  and  neck  takes  from  the  socket  one  of  the 
supports  on  which  the  trunk  rests,  and  the  hip  is  more  mutilated  than 
after  the  cure  by  the  natural  process  of  gradual  absorption,  repair, 
and  cicatrization,  which  leaves  a  firm  though  possibly  ankylosed  hip. 


88  ORTHOPEDIC  SURGERY 

The  operation  is  therefore  reserved  for  the  cases  where  loose 
sequestra  are  present,  in  children  where  conservative  measures  have 
failed  and  life  is  threatened,  and  in  adults  where  time  for  conservative 
treatment  is  impossible. 

Operative  Dislocation  of  the  Hip. — In  the  natural  cure  of  hip  dis- 
ease the  head  is  gradually  pushed  out  of  the  normal  acetabulum  and 
the  opposed  inflamed  joint  surfaces  freed  from  the  irritation  of  mutual 
pressure  heats. 

The  method  of  operative  dislocation  has  been  employed  by  one 
of  the  writers  in  3  advanced  cases  of  extensive  disease  when  the 
acetabulum  was  involved. 

One  died  6  months  later  of  amyloid  disease;  the  ultimate  result 
was  not  known  in  the  second ;  the  third  recovered  completely,  and  was 
seen  10  years  later,  strong  and  well,  with  a  serviceable  limb,  with  the 
characteristic  distortion  of  a  cured  but  dislocated  hip,  a  distortion 
which  could  be  corrected  by  osteotomy. 

The  operation  of  artificial  dislocation  is  performed  by  means  of 
the  incision  needed  in  excising  the  hip.  The  femoral  head  is  dislo- 
cated after  being  freed,  carious  surfaces  are  curetted  and  wiped  with 
alcohol,  and  ample  drainage  of  the  acetabulum  provided  by  drainage 
tubes.  The  diskcated  limb  is  securely  flexed  and  adducted  by  a  strong 
plaster-of-Paris  spica.  Ambulatory  treatment  is  encouraged  as  soon 
as  possible. 

The  operation  of  amputation  at  the  hip-joint  has  been  performed 
three  times  at  the  Boston  Children's  Hospital  in  extensive  disease  of 
the  hip  and  pelvis,  with  operative  success  in  all,  but  with  ultimate 
death  from  amyloid  disease  in  two  cases.  Ultimate  recovery  took 
place  in  one  who  grew  to  manhood  and  at  twenty  wore  an  artificial 
limb  fitted  to  a  stump  in  which  reformation  of  the  bone  took  place 
from  the  periosteum. 

SUMMARY  OF  TREATMENT  OF  HIP  DISEASE 

It  is  difficult  to  summarize  the  treatment  of  hip  disease,  for  the 
reason  that  cases  differ  greatly  in  severity;  some  needing  fixation  for 
a  very  long  period,  owing  to  a  severe  degree  of  sensitiveness  or  to 
the  activity  of  the  ostitis,  while  in  other  cases  ambulatory  treatment 
with  proper  appliances  is  sufficient  without  recumbency. 

The  proper  treatment  of  hip  disease  is,  therefore,  not  the  exclusive 
use  of  any  method,  but  the  use  of  such  means  as  may  meet  the  indica- 
tions as  they  are  present.  During  the  acutest  stages,  the  hip-joint 


TUBERCULOUS  DISEASE  OF  THE  HIP  89 

should  be  fixed  efficiently  in  bed.  Thorough  traction  is  needed  to 
check  severe  muscular  spasm.  A  long  plaster  spica  extending  well 
up  on  the  trunk  furnishes  serviceable  but  cumbersome  fixation.  Con- 
tinued confinement  to  bed  is  not  beneficial  to  the  general  condition 
of  tuberculous  patients,  except  temporarily  during  the  acute  stage; 
and  as  soon  as  the  acute  symptoms  have  subsided  the  patient  should 
be  allowed  to  go  about  with  the  hip  thoroughly  protected  against  jar 
and  spasm.  This  can  be  done  by  means  of  a  traction  splint,  if  ef- 
ficiently applied,  with  at  first  the  additional  protection  from  crutches. 

If  the  acute  symptoms  return  under  this  method,  thorough  rest 
in  bed  is  again  indicated  in  addition  to  efficient  traction  and  fixation. 
If  the  acute  symptoms  diminish  and  there  is  less  muscular  rigidity 
at  the  hip- joint,  greater  freedom  can  again  be  allowed,  and  the  joint 
merely  protected  from  jar.  This  should  be  continued  so  long  as  there 
is  any  danger  of  recurrence  of  active  symptoms  or  tendency  to 
contraction. 

In  brief,  the  hip  should  be  fixed  as  long  as  it  is  sensitive,  should 
be  protected  and  distracted  as  long  as  there  is  muscular  spasm,  and 
protected  until  the  congested  and  inflamed  bone  of  the  epiphysis 
is  replaced  by  firm,  healthy  bone.  Distortions  of  the  limb  should 
always  be  corrected  as  they  occur.  In  many  cases  some  motion  can 
be  saved  at  the  hip- joint  if  treatment  is  not  discontinued  too  soon 
and  begun  before  joint  destruction  has  become  extensive  and  thor- 
oughly carried  out  until  the  joint  is  cured. 

The  advantage  of  the  employment  of  traction  during  the  acute 
stages  of  hip  disease  has  been  demonstrated  at  the  service  of  the 
Boston  Children's  Hospital,  the  ultimate  results  5  years  after  the 
cessation  of  treatment  in  a  series  of  cases  having  been  examined.  In 
a  large  number  of  cases,  pathological  dislocation,  i.e.,  elevation 
of  the  trochanter  above  Nelaton's  line,  had  been  prevented  in  70  per 
cent  of  the  cases,  while  statistics  of  ultimate  results  in  other  clinics 
show  pathological  dislocation  in  all  cases  where  traction  has  not  been 
used.1 

In  the  experience  of  the  writers,  considering  the  cases  as  a  whole 
over  a  period  of  many  years,  the  treatment  in  which  traction  has 
been  thoroughly  employed  yields  far  better  end  results  than  any 
other  form  of  fixation  without  traction. 

Abscesses  can  be  treated  on  general  surgical  principles.  Radical 
operative  measures  are  needed  only  in  exceptional  cases  if  thorough 
conservative  treatment  can  be  secured.  Out-of-door  air,  the  best 

^'Traction  in  Hip  Disease,"  Am.  Jour.  Med.  Sciences,  December,  1908. 


90  ORTHOPEDIC  SURGERY 

obtainable  surroundings,  with  as  much  activity  as  the  local  conditions 
of  the  joint  justify,  and  improving  the  appetite  and  the  metabolism, 
are  the  antidotes  at  present  available  for  the  tuberculous  condition. 
These,  if  combined  with  such  surgical  treatment  as  will  protect  the 
affected  bone  from  frequent  traumatism,  may  be  relied  upon  to 
effect  a  cure  in  the  greater  number  of  cases  of  hip  disease. 


CHAPTER  IV. 

TUBERCULOUS  DISEASE  OF  THE  KNEE. 

DEFINITION. 

THIS  affection  is  also  known  as  tumor  albus,  or  white  swelling. 

Tumor  albus  in  children  begins  oftenest,  if  not  always,  as  an  epi- 
physeal  ostitis  of  the  tuberculous  type.  Like  other  forms  of  tubercu- 
lous disease,  it  is,  as  a  rule,  limited  to  certain  portions  of  the  epiphysis, 
and  either  the  femoral  or  tibial  epiphysis  may  be  attacked  primarily. 
Cases  are  occasionally  seen,  however,  in  which  the  primary  focus  is  in 
the  patella  or  in  the  head  of  the  fibula. 

CLINICAL   HISTORY. 

The  affection  begins  with  limp  and  limitation  of  motion.  The 
disease  is  usually  slow  in  progress,  but  there  may  be  periods  of  severe 
pain.  Swelling  of  the  periarticular  tissues,  periarticular  abscess,  and 
distortion  of  the  limb  may  result,  ending  in  flexion  and  subluxation 
of  the  limb  with  fibrous  or  bony  ankylosis ;  or  the  affection  may  result 
in  such  extensive  suppuration  as  to  endanger  life  from  septic  or 
amyloid  changes. 

Swelling. — In  tumor  albus  the  knee  will  be  seen  to  have  lost  its 
definite  contour,  the  depressions  on  the  sides  of  the  patella  have 
become  filled  out  so  that  there  is  an  indistinctness  of  outline  which 
is  as  perceptible  to  the  touch  as  to  the  sight.  Most  often  the  patella 
seems  to  be  raised  from  its  position  by  a  semi-solid  mass  and  the 
whole  knee  seems  surrounded  by  a  boggy  infiltration.  Later  it 
assumes  a  spindle  shape  and  the  distention  causes  the  skin  to  be  some- 
what anaemic  in  the  more  severe  cases,  whence  the  name  of  tumor 
albus. 

The  swelling  at  the  knee,  unless  suppurative  synovitis  is  present 
to  a  marked  degree,  differs  from  that  of  synovitis  with  effusion,  in 
that  the  swelling  is  of  the  bone  and  soft  periarticular  tissue,  and  is 
not  altogether  within  the  joint. 

In  some  instances,  one  of  the  condyles — usually  the  internal 
condyle — is  enlarged  more  than  the  other,  causing  knock-knee. 

91 


ORTHOPEDIC  SURGERY 


Atrophy. — Atrophy  of  the  muscles,  both  of  the  thigh  and  calf, 
is  present,  and  reaches  a  serious  degree  in  acute  cases.  It  is  more 
equally  distributed  between  the  muscles  of  the  thigh  and  those  of  the 
leg  than  in  hip  disease.  The  affected  limb  is  likely  to  be  longer  than 
the  other,  owing  to  the  congestion  of  the  epiphysis  of  the  knee. 

Pain. — The  pain  of  the  affection  is,  except  during  the  acute  exacer- 
bations, not  severe,  though  pain 
on  jarring  the  limb  is  common. 
Xight  cries  are  much  less  common 
than  in  hip  disease,  but  they  occur. 
When,  however,  the  patient  does 
suffer  from  an  acute  exacerbation, 
the  pain  and  tenderness  are  ex- 
cessive. From  the  exposed  condi- 
tion of  the  joint  jars  and  twists 
are  very  common,  and  the  suffer- 
ing may  be  extreme.  Tenderness 
is  very  common,  especially  over 
the  inner  surface  of  the  head  of 
the  tibia.  In  certain  cases,  how- 
ever, the  knee  is  held  rigid  by 
muscular  spasm,  and  any  reason- 
able manipulation  fails  to  occa- 
sion any  pain. 

Heat. — Heat  of  the  affected 
joint  may  be  present  in  the  more 
acute  stage. 

Lameness — Lameness  is  a 
constant  symptom.  It  varies  with 
the  sensitiveness  of  the  joint  and 
is  much  influenced  by  the  amount 
of  flexion  present  in  the  diseased 
knee. 

Muscular  Fixation. — Muscu- 
lar fixation  is  a  symptom  of  this 
as  of  all  chronic  tuberculous  ostitis,  but  is  less  prominent  than  in  the 
hip.  In  the  early  stages  it  may  be  slight.  The  joint  may  be  held  per- 
fectly rigid  or  in  partial  flexion,  or  a  certain  arc  of  motion  may  be 
permitted.  Persistent  muscular  spasm  results  in  the  characteristic 
malpositions  of  the  affection:  flexion,  and  subluxation  of  the  tibia. 

Deformity. — Malpositions    of   the    liuib    result    from    the    greater 


FIG.  85. — Tuberculous  Knee  in  Adult.  Gen- 
eral synovial  tuberculosis.  Large  irregular 
area  of  tuberculous  softening  in  epiphyseal 
end  of  femur,  extending  into  joint  along 
crucial  ligaments.  (Nichols.) 


TUBERCULOUS  DISEASE  OF  THE  KNEE 


93 


power  the  flexor  muscles  of  the  thigh  possess  in  contrast  to  the  exten- 
sors. The  limb  becomes  gradually  flexed  almost  from  the  first,  and 
if  the  affection  goes  on  without  treatment,  flexion  may  reach  a  right 


FIG.  86. — Subluxation  in  Tumor  Albus. 

angle,  and  this  is  the  tendency  of  the  disease  throughout  and  a  marked 
obstacle  to  its  successful  treatment. 

Even  when  the  affection  is  nearly  cured  or  after  a  slight  injury  of 
the  joint  flexion  may  return,  which  is  accompanied  by  increased  heat 
and  tenderness.  Together  with  the  flexion,  and  as  a  result  also  of  the 
predominance  of  the  flexor  muscles  of  the  thigh,  subluxation  of  the 


FIG.  87. — Tuberculosis  of  Knee-joint  with  Extreme  Flexion  Deformity. 

tibia  backward  occurs  at  a  later  stage  of  the  affection;  this  is  due  to 
the  shape  of  the  joint  surfaces  and  the  persistent  contraction  of  the 
hamstring  muscles  always  pulling  the  tibia  backward.  If  the  leg  has 
assumed  this  distortion  and  is  straightened  without  an  attempt  to 


94 


ORTHOPEDIC  SURGERY 


correct  the  subluxation,  the  tibia  will  lie  in  a  plane  back  of  that  of  the 
femur,  and  the  part  of  the  knee  formed  by  the  femur  and  patella 
will  be  unduly  prominent. 

Another  result  of  long-continued  muscular  spasm  is  the  external 
rotation  of  the  tibia  upon  the  femur,  which  accompanies  severe  grades 
of    flexion    and    persists    after 
straightening  of  the  leg  if  such 
is  accomplished.     In  the  same 
way     a     certain     amount     of 
knock-knee  is  apt  to  be  present 
in  the  corrected  limb  after  se- 
vere grades  of  tumor  albus. 

Abscess — Abscess  appears 
either  as  a  purulent  distention 
of  the  capsule,  which  may  point 
at  any  part  of  the  surface  and 
discharge  by  sinuses  for  an  in- 
definite time,  or  abscesses  form 
in  the  periarticular  tissues  as  in 
hip  disease. 

DIAGNOSIS. 

The  diagnostic  symptoms 
and  signs  in  tumor  albus  are 
an  intermittent  lameness;  a 
general  enlargement  of  the 
knee-joint,  with  a  feeling  of 

stiffness  and  pain  on  using  the  limb;  heat  over  the  joint;  and  the 
presence  of  local  tenderness  and  muscular  stiffness  in  manipulation 
of  the  joint. 

PROGNOSIS. 

The  prognosis  of  tumor  albus  is  similar  to  that  of  the  same  affec- 
tions of  the  other  large  joints.  The  functional  results  after  conserva- 
tive treatment  are  in  average  cases  excellent;  when  efficient  treatment 
is  begun  at  an  early  stage  sometimes  perfect  motion  is  restored,  but 
if  the  process  is  not  arrested  an  incomplete  arc  remains  and  not  infre- 
quently complete  rigidity  may  result.  The  earlier  treatment  is  begun 
and  the  more  faithfully  it  is  carried  out,  the  better  is  the  outlook  as 
to  functional  result.  In  advanced  cases  disability  follows,  and  in 
neglected  cases  deformity  of  the  limb,  flexion  at  the  knee,  subluxation 


FIG.  88. — Position  of  Deformity  in  Tumor  Albus. 


TUBERCULOUS  DISEASE  OF  THE  KNEE  95 

of  the  tibia,  and  the  formation  and  discharge  of  abscesses  are  likely 
to  occur,  ending  either  in  a  complete  destruction  of  the  joint  or  in  a 
cure  with  ankylosis. 

As  in  all  cases  of  epiphyseal  ostitis  of  the  larger  joints,  the  progno- 
sis as  to  the  time  of  requisite  treatment  depends  not  only  on  the  time 
needed  to  check  the  inflammation,  but  also  for  the  re-establishment 


FIG.  89. — Severe   Tuberculoses  of   Knee-joint  with   Marked   Swelling,    Flexion,   and   Sinus. 

of  sound  bone  tissue  capable  of  bearing  weight  without  danger  of 
relapse.  This  in  growing  children  demands  a  long  time.  Protection 
is  generally  necessary  for  from  one  to  two  years. 

TREATMENT. 

CONSERVATIVE  TREATMENT  OF  TUMOR  ALBUS. 

What  was  said  in  regard  to  the  treatment  of  hip  disease  may  be 
repeated  in  speaking  of  epiphysitis  of  the  knee-joint.  The  treatment 
should  be  thorough  and  persistent,  and  should  meet  the  indications, 
fixation  and  protection  being  the  most  important  of  these  in 
diseases  of  the  knee.  The  employment  of  protection  should  be  con- 
tinued until  the  epiphysis  is  normal  in  strength.  Protection  should  be 
discontinued  gradually  and  tentatively;  if  discontinued  too  soon, 
recurrence  will  take  place,  or  deformity  of  the  limb  will  develop. 
Fixation  should  be  used  so  long  as  there  is  any  activity  of  the  inflam- 
mation. 


96  ORTHOPEDIC  SURGERY 

In  the  acutest  stage  it  may  be  necessary  to  keep  the  patient  in  bed, 
but  ordinarily  this  acute  stage  is  absent  or  is  brief,  and  ambulatory 
treatment  is  both  possible  and  desirable. 

Fixation. — Fixation  by  stiff  bandages  is  an  efficient  method  of 
treatment  when  the  bandages  are  properly  applied.  They  should  reach 


FIG.  go. — Tuberculosis  of  Knee-joint  with 
Abscess. 

from  the  groin  to  the  ankle,  in  the  acute  cases  including  the  foot,  and 
as  firmly  as  possible  grasp  the  muscles  of  the  limb. 

Protection. — Protection  from  the  jar  of  weight-bearing  locomo- 
tion can  be  furnished  by  means  of  crutches  and  raising  the  sound 
limb  by  a  thick  sole  which  allows  the  affected  limb  to  swing  clear  of 
the  ground.  Better  protection  is  furnished  by  means  of  a  splint  with 
perineal  support  and  longer  than  the  limb,  which  passes  below  the 
foot  so  as  to  take  the  jar  of  locomotion. 

Thomas  Knee-Splint. — A  simple  but  efficient  appliance  is  the 
Thomas  knee-splint,  which  consists  of  a  padded  iron  ring  fitted  so  as 


TUBERCULOUS  DISEASE  OF  THE  KNEE 


97 


to  surround  the  thigh  at  the  perineum,  and  fastened  to  two  rods  on 
each  side  of  the  limb,  longer  than  the  limb  and  secured  at  the  bottom 
to  a  metal  plate  below  the  foot. 

The  leg  can  be  fixed  by  means  of  bandages  and  leather  bands 
attached  to  the  splint.     With  this  splint  applied,  the  patient  sits  in  a 


FIG.  91. — Radiograph  of  Tuberculosis  of  Knee  joint.  Showing  Destruction  of  Joint  Surface  and  Bone, 

Flexion  and  Subluxation  of  Tibia. 

ring  supporting  the  perineum,  while  uprights  run  below  the  foot  and 
bear  the  body  weight. 

In  acute  cases  and  cases  tending  to  flexion  the  use  of  a  plaster-of- 
Paris  splint  in  addition  to  the  Thomas  splint  is  desirable,  as  better 
fixation  is  secured  than  by  bandages  alone. 

The  Thomas  splint  is  slung  from  the  shoulder  by  means  of  a  strap, 
and  the  well  limb  is  raised  by  means  of  a  cork,  wooden,  or  steel  patten. 
Crutches  are  not  necessary  in  connection  with  the  Thomas  splint. 


98  ORTHOPEDIC  SURGERY 

Calliper  Splint. — When  the  condition  of  the  limb  has  improved  so 
much  that  spasm  and  sensitiveness  are  absent,  or  in  mild  cases,  the 
Thomas  splint  can  be  shortened  and 
the  ends  slotted  into  the  sole  of  the 
shoe  at  such  a  length  as  to  keep  the 
heel  from  touching  the  ground.  In 
this  way  the  patient  walks  about  sus- 
pended by  the  perinea!  ring  and 
bearing  but  little  weight  on  the  dis- 
eased joint. 

\Vhen  convalescence  has  been 
further  established  and  protected 
motion  at  the  joint  is  possible,  the 
knee  splint  may  be  jointed  with  a 
spring  catch  and  check  to  limit  the 
amount  of  motion. 

The  treatment  by  passive  hyper- 
nemia  and  dry  heat  is  useful  if  at  all 

the    milder    and    more    chronic 


in 
cases. 

Treatment  of  Complications. — 
Deformity. — Flexion  of  the  knee  is 
commonly  seen  even  in  the  early 
stage  of  the  affection,  associated  in 
the  early  part  of  the  disease  with  an 
acutely  sensitive  condition  of  the 
joint,  or  it  may  develop  gradually 
without  pain. 

A  flexed  knee-joint  may  be 
straightened  by  the  employment  of 
a  correcting  force  applied  to  the  pa- 
tient in  bed;  by  applying  a  succes- 
sion of  plaster-of-Paris  bandages, 
each  straighter  than  the  last;  by  em- 
ploying force  under  an  anaesthetic. 

Forcible  Correction  of  Flexion. 
—In    cases    without    adhesions    the 

knee  is  easily  put  in  a  correct  position  with  the  use  of  little  or  no 
force  under  complete  anaesthesia.  If  the  leg  is  allowed  to  remain  in 
the  fixed  position,  angular  ankylosis  will  probably  occur.  When  firm 
adhesions  have  been  formed  at  the  knee-joint,  correction  by  means 


FIG.    92. — Jointed    Traction    Knee    Splint 
Applied. 


TUBERCULOUS  DISEASE  OF  THE  KNEE 


99 


of  appliances  will  be  found  tedious,  painful,  and  sometimes  impossible, 
and  generally  forcible  correction  of  some  sort  will  be  necessary  to 
break  down  the  adhesions.  One  way  is  to  break  down  the  adhesions 
by  forcibly  flexing  the  leg,  and  then  by  forcible  extension  to  straighten 
it.  The  danger  of  rupturing  the  popliteal  artery,  which  has  occurred, 
is  in  this  way  diminished.  Many  appliances  have  been  devised  to 


FIG.  93. — Imperfect    fixation   of   Knee-joint 
by    Loose   Plaster    Bandage. 


FIG.  94. — Thomas  Knee 
Splint  with  Ring  Cov- 
ered and  Posterior 
Leather  Attached. 


give  greater  power  in  forcible  correction.  A  procedure  not  requiring 
the  use  of  apparatus  is  as  follows:  The  patient  is  placed  upon  the 
floor  upon  the  back  and  the  surgeon  stands  over  the  patient,  holding 
the  flexed  knee  with  both  hands,  the  fingers  being  placed  under  the 
popliteal  space.  The  whole  weight  of  the  surgeon's  trunk  can  be 
thrown  upon  the  end  of  the  lever  furnished  by  the  patient's  leg,  the 
hands  of  the  surgeon,  pulling  upon  the  popliteal  space,  furnishing 
resistance.  After  the  limb  has  yielded  and  the  adhesions  are  broken, 
it  can  be  straightened  if  the  patient  is  turned  upon  the  face;  a  down- 


IOO 


ORTHOPEDIC  SURGERY 


ward  force  being  applied  to  the  heel,  resistance  being  furnished  by  a 
cushion  placed  under  the  patient's  knee.     After  correction,  the  limb 


FIG.  95. — Side  View  of   Ring  of  Thomas  Knee   Splint   Uncovered  and   Covered,   Showing  Proper 
Shape.       (Drawn    from    Ridlon   and   Jones.) 

should  be  well  surrounded  with  sheet-wadding  and  a  stiff  bandage 
applied,  the  limb  being  held  straight  until  the  plaster  has  become  hard. 
The  dangers  incurred  by  this  pro- 
cedure are  not  so  great  as  would 
be  supposed.  The  danger  of  rup- 
ture of  the  artery  can  be  avoided 
by  care.  Separation  of  the 
epiphysis  of  the  femur  may  take 
place,  but  is  cured  by  the  fixation 
requisite  to  treatment,  and  should 
not  occur  if  the  force  is  carefully 
applied.  Fracture  of  the  femur 
and  tibia  can  be  avoided  by  care. 
If  the  flexion  deformity  re- 
mains uncorrected  in  severe  os- 
titis  of  the  knee-joint,  a  subluxa- 
tion  of  the  tibia  backward  takes 
place,  due  to  the  contraction  of 
the  hamstring  muscles.  This  subluxation  can  often  be  corrected  by 
placing  the  patient  upon  the  face  and  exerting  a  pulling  force  upon 


FIG.  96.- — View  of  Front  and  Rack  of  Ring 
of  Thomas  Knee  Splint  Covered,  Showing 
Depression  at  Hack  for  Tuberosity  of 
Ischium.  (Drawn  from  Ridlon  and  Jones.) 


UERf-FY  OF 
TUBERCULOUS  DISEASE  OFCFIIE-  BME&  "         W^  F 

the  head  of  the  tibia,  the  front  of  the  thigh  resting1  ofi  the  operating 
table,  the  leg  being  gradually  straightened. 

In  resistant  cases  mechanical  force  can  be  used  as  indicated  in  the 
accompanying  illustration. 

Pressure  forward  on  the  head  of  the  tibia  is  exerted  by  turning 


FIG.  97.— Thomas  Cal- 
liper Splint,  with  Pads, 
Applied.  (Ridlon  and 
Jones.) 


FIG. 


3. — Old  Tumor  Albus  Recovered  with  Motion,  Showing 
Subluxation  of  Tibia. 


the  handle;  this,  by  means  of  a  screw  force,  pushes  a  plate  forward 
against  the  tibia,  working  through  a  band.  The  calf  muscles  protect 
the  artery  and  nerve  from  injurious  pressure.  Counter-pressure  is 
secured  by  means  of  leather  straps,  which  are  passed  respectively  over 
the  knee  and  leg,  protected  by  a  thick  layer  of  saddler's  felt.  Several 
straps  will  be  needed  at  the  knee  to  prevent  loss  of  counter-pressure, 
as  the  limb  is  made  straighten  Another  strap,  under  the  leg,  secures 


IO2 


ORTHOPEDIC  SURGERY 


the  lower  part  of  the  leg.    The  side  bars,  bands,  and  plate  of  the  appa- 
ratus should  be  of  strong  steel. 

When  bone  ankylosis  is  present  the  flexion  deformity  can  be  cor- 
rected by  linear  osteotomy. 


FIG.   99. — Genuclast  for  Correcting  FIG.  100. — Genuclast  Applied   to   Flexed   Knee. 

Flexion  cf  Knee. 


Abscess. — The  treatment  of  abscess  is  the  same  that  is  recom- 
mended for  the  treatment  of  abscesses  at  the  hip,  except  that  they  are 
generally  more  superficial  and  can  be  opened  earlier.  They  do  not 
dissect  about  between  the  muscles  to  the  extent  that  hip  abscesses 
often  do. 


TUBERCULOUS  DISEASE  OF  THE  KNEE 
OPERATIVE  TREATMENT  OF  TUMOR  ALBUS. 


103 


The  operative  measures  to  be  considered  are : 

1.  Excision. 

2.  Arthrectomy  or  erasion. 

3.  Amputation  of  the  leg. 

i.  Excision  of  the  knee-joint  is  to  be  undertaken  in  those  cases  in 
which  conservative  treatment  has  failed  to  arrest  the  progress  of  the 


FIG.   101. — Result  of   Excision  of  Knee  in  Childhood  with  Injury  to  Epiphyseal   Lines. 

disease;  in  which  originally  the  disease  is  too  extensive  to  warrant 
conservative  treatment;  in  which  the  general  health  is  fail- 
ing and  the  disease  failing  to  improve  under  efficient  conservative 
measures.  The  operation  of  excision  should  not,  however,  be  per- 


104 


ORTHOPEDIC  SURGERY 


formed  in  young  children  for  tuberculous  disease  of  the  knee,  as  the 
growth  of  the  limb  may  be  checked  thereby. 

Excision  of  the  knee  is  also  performed  to  correct  the  deformity 
caused  by  bony  ankylosis  at  an  angle  of  flexion. 

OPERATION. — The  operation  of  excision  of  the  knee-joint  is  per- 
formed as  follows : 

The  leg  should  be  carefully  prepared  for  aseptic  operation.  The 
use  of  the  Esmarch  bandage  and  tourniquet  is  advisable.  The  joint 
is  opened  by  a  free  anterior  incision  passing  from  the  inner  to  the 
outer  side  of  the  joint  slightly  below  the 
patella,  the  ligamentum  patelhe  is  divided, 
the  periosteum  and  muscular  attachments 
are  cleared  from  the  ends  of  the  bones,  the 
ligaments  are  cut.  and  the  articular  end  of 
the  femur  protruded  through  the  incision 
and  as  much  as  seems  desirable  sawed  off. 
In  the  same  way  the  tibia  is  cleared  and 
protruded  as  a  safeguard  against  injuring 
the  popliteal  vessels.  The  patella  should  be 
removed  if  it  is  diseased.  In  children  it 
is  essential  if  the  operation  of  excision  is 
performed  to  avoid  removing  bone  below 
the  line  of  the  epiphysis. 

Apparatus  is  to  be  worn  for  some  time 
to  prevent  the  recurrence  of  flexion. 

Excision  of  the  Knee  for  Angular  Anky- 
Icrsis. — \Yhen  excision  of  the  knee  is  done 
for  angular  ankylosis.  the  only  modification 
of  the  operation  which  is  necessary  is  the 
removal  of  a  wedge  of  bone  large  enough 
to  allow  the  ends  of  the  bone  to  come  to-  FlG  ;o2._Osteotomy  for  Deform. 
gether.  so  that  the  anoularitv  is  obliterated.  Jty  with  Ankylosis.  (After 

_  .     .        .  .  Hoffa.) 

Osteotomy  of  the  femur  is  a  measure  to 

be  preferred.  The  osteotomy  should  be  linear  and  as  near  the  joint 
epiphyseal  line  as  possible.  Either  the  lower  end  of  the  femur  or 
upper  part  of  the  tibia  can  be  divided. 

Operation   to  Correct  Stiffness  of  the  Joint To  overcome  the 

stiffness  which  remains  after  all  inflammatory  processes  have  passed, 
the  joint  can  be  opened,  by  means  of  two  lateral  incisions — the  patella 
and  the  ankylosed  bones  freed  by  dissection  and  kept  apart  by 
wrapping  around  each  bone  several  layers  of  prepared  animal  mem- 


TUBERCULOUS  DISEASE  OF  THE  KNEE  105 

brane  or  fascia.  The  membrane  should  be  stretched  around  the 
ends  of  the  bone  and  the  patella  to  prevent  the  reformation  of  ad- 
hesions. A  prepared  membrane  from  a  pig's  bladder  has  been  used — 
as  sufficiently  durable — but  adequate  durability  can  be  secured  if 
several  layers  of  prepared  Cargile  membrane  are  used. 

2.  Arthrectomy. — As  a   substitute    for  excision,    what  has  been 
termed  arthrectomy  or  erasion  has  been  employed. 

Arthrectomy  consists  of  the  removal  of  all  palpable  and  obvious 
portions  of  diseased  tissue,  whether  in  the  synovial  membrane  or  else- 
where, leaving  what  appears  to  be  healthy  tissue.  Two  advantages 
are  claimed  for  this  operation  over  excision :  ( i )  That  it  does  not 
interfere  with  the  growth  of  the  limb,  and  (2)  that  mobility  of  the 
joint  may  sometimes  be  preserved. 

OPERATION. — The  joint  is  opened  as  in  cases  of  excision  and  the 
tuberculous  synovial  membrane  as  far  as  possible  should  be  dissected 
out;  if  diseased  spots  are  found  in  the  bone,  these  foci  should  be 
removed  by  the  curette  or  chisel,  and  the  cavity  left  in  the  bone  wiped 
out  with  pure  carbolic  acid  and  alcohol,  and  the  joint  sewed  up  or 
drained  according  to  the  extent  of  the  disease  and  the  general  aspect 
of  the  case.  If  the  whole  epiphysis  is  diseased,  excision  is  of  course 
unavoidable.  Instances  of  excellent  recovery  with  complete  healing 
occur  after  this  operation,  and  success  has  followed  the  procedure  in 
many  cases  in  the  practice  of  the  writers.  The  most  thorough  removal 
possible  of  all  tuberculous  tissue  in  the  affected  joint  is  essential, 
necessitating  sometimes  complete  dissection  and  removal  of  all  of  the 
synovial  membrane,  as  well  as  careful  curetting  of  the  bone.  The 
patella  should  be  removed  or  left,  according  to  its  condition. 

The  parts  of  the  knee-joint  to  be  most  carefully  investigated  for 
diseased  foci  are  the  synovial  pockets  and  the  epiphyseal  lines  of  the 
femur  and  tibia  at  their  lateral  aspects.  Here  one  may  find  foci  of 
tuberculous  material  extending  into  the  epiphysis,  without,  however, 
in  most  cases  crossing  the  epiphyseal  lines.  The  after-treatment 
should  be  like  that  of  excision. 

Flexion  of  the  limb  may  follow  arthrectomy  as  well  as  excision 
in  cases  in  which  protection  to  the  joint  has  been  discontinued  too 
early,  so  that  the  after-treatment  should  be  as  careful  and  as  prolonged 
as  after  excision  of  the  joint. 

3.  Amputation. — In  extreme  cases  of  disease  of  the  knee-joint 
amputation  of  the  thigh  is  necessary  as  a  life-saving  measure. 


CHAPTER  V. 


TUBERCULOUS    DISEASE    OF   THE   ANKLE   AND    OTHER 

JOINTS. 

ANKLE. 

THE  seat  of  the  disease  may  be  in  the  articular  end  of  the  tibia  or 
in  the  astragalus  or  in  any  of  the  bones  of  the  tarsus.  The 
astragalus,  however,  is  the  most  common  seat  of  disease. 

Symptoms. — Pain  in  the  joint  on  motion  may  or  may  not  be 
present.  Tenderness  is  often  present  over  the  joint  capsule  in  front, 
and  perhaps  under  the  malleoli,  and  swelling  and  heat  are  frequent 
accompaniments  of  the  affection. 

Lameness  is  an  early  and  a  marked  symptom.  The  swelling  con- 
sists of  an  infiltration  of  the  soft  parts  around  the  ankle.  The  depres- 
sions in  the  contour  of  the  ankle  in 
front  and  behind  the  malleoli  dis- 
appear. The  foot  in  affections  of 
the  ankle-joint  usually  assumes  a 
position  with  the  toes  pointing 
downward,  and  in  chronic  cases 
with  the  foot  slightly  rolled  outward 
(in  the  position  of  equino-valgus). 
This,  however,  is  not  the  only  mal- 
position, for  the  foot  may  assume 
the  position  of  pure  talipes  calcaneus. 

When  the  disease  attacks  the 
medio-tarsal  or  tarso-metatarsal 
joints,  the  anterior  part  of  the  in- 
step appears  swollen  and  may  be 
hot  and  tender.  Motion  at  the 
ankle  may  be  somewhat  restricted  in 
the  midtarsus.  If  the  os  calcis  is 
attacked  primarily  it  is  manifested 
by  the  same  symptoms  of  local  in- 
flammation without  any  symptoms  referable  to  the  ankle-joint. 

Diagnosis. — The  diagnosis  is  based  on  the  fact  that  the  affection  is 

106 


FIG.     103. — Ankle-joint     Disease 
Early   Stage. 


TUBERCULOUS  DISEASE  OF  THE  ANKLE 


107 


a  chronic  one  and  is  more  common  in  children  than  a  monarticular 
"  rheumatic  "  affection.  Swelling,  limited  motion,  sensitiveness,  and 
pain  are  symptoms. 

The  ^r-ray  is  of  value  in  establishing  the  diagnosis. 

Prognosis. — Unless  the  disease  is  advanced,  children  who  are  in 
good  condition  as  a  rule  make  good  progress  under  conservative  treat- 


FIG.    104. — Tuberculous  Ankle.     Advanced   Stage. 


ment.  The  prognosis  is  somewhat  better  when  parts  other  than  the 
astragalo-tibial  joint  are  affected.  The  prognosis  in  adults  under 
conservative  treatment  is  less  favorable. 

Mechanical  Treatment. — Protection  from  jar  is  indicated,  as  well 
as  fixation  of  the  joint,  when  the  astragalus  is  affected — as  will  be 
readily  seen  if  it  be  borne  in  mind  that  in  locomotion  the  whole 
weight  of  the  body  is  borne  at  each  step  upon  the  comparatively  small 
surface  of  the  upper  articulating  portion  of  the  astragalus.  A  plaster- 
of-Paris  bandage  is  the  most  convenient  appliance  for  fixation,  and 
should  be  carried  above  the  knee  so  as  to  fix  that  joint  also.  Protec- 
tion can  be  furnished  either  by  means  of  crutches  or,  more  thoroughly, 
by  means  of  a  perineal  support.  The  Thomas  knee-splint  is  a  service- 
able apparatus. 

Such  apparatus  for  fixation  and  protection  should  be  worn  until 


io8 


ORTHOPEDIC  SURGERY 


the  bone  is  sufficiently  cicatrized  to  stand  the  strain  incident  to  loco- 
motion. If  abscesses  form  they  should  be  incised  and  traced  to  their 
source,  and  if  loose  bone  is  detected  this  should  be  removed.  If  the 
foot  assumes  a  malposition,  this  should  be  corrected  by  applying 
plaster  bandages.  The  general  health  should  be  carefully  inquired  into 
and  appropriately  treated.  All  these  procedures  may  be  grouped  to- 
gether and  be  said  to  complete  the  expectant  method  of  treatment. 

The  conservative  plan   fully  carried  out  is  justifiable  in  a  large 
proportion  of  cases,  and  on  the  whole  the  results  obtained  are  good. 


FIG.   105. — Radiograph    of    Ankle    Ten    Years   after    Cure    following    Removal    of   Astragalus    for 
Disease.      (Case   of    Dr.    A.    T.    Cabot.) 

Operative  Treatment. — When  expectant  treatment  fails,  operative 
measures  should  be  resorted  to.  Curettage  of  the  small  bones  of  the 
tarsus  is  inadvisable  when  conservative  treatment  fails — the  affected 
tarsal  bone  should  be  removed  entirely. 

The  method  of  choice  for  opening  the  joint  and  removal  of  a 
diseased  bone  is  as  follows :  The  foot  is  held  at  a  right  angle  and 
a  superficial  incision  is  made  along  the  outer  border  just  below  the 
external  malleolus,  reaching  from  the  tendo  Achillis  to  the  extensor 
tendons.  The  peroneal  tendons  are  dissected  out,  secured  by  sutures, 
and  then  cut  by  a  second  and  deeper  incision.  The  capsule  along  the 
anterior  and  posterior  surfaces  of  the  tibia  is  cut,  the  external  lateral 
ligament  divided,  and  the  ankle-joint  thus  opened  freely  from  the 
side.  The  foot  is  then  dislocated  inward  as  far  as  is  desired,  and 
the  joint  can  be  inspected  to  any  extent.  After  the  diseased  parts  have 


TUBERCULOUS  DISEASE  OF.  THE  SHOULDER         109 

been  removed,  the  foot  is  reduced  to  its  proper  position,  the  peroneal 
tendons  are  united,  and  the  wound  is  closed.     When  the  foot  is  dis- 
located, an  admirable  view  is  obtained  of 
the  interior  of  the  joint. ; 

The  after-treatment  of  cases  of  ankle- 

^1  joint  excision  is  similar  to  the  treatment  of 

the  other  joints   spoken   of.     Asepsis  and 
^^g^^  immobilization  in  a  correct  position  are  the 

requirements;  and  to  this  end  infrequent 
dressings  are  very  desirable.  Plaster-of- 
Paris  applied  outside  of  a  heavy  dressing 
is  serviceable,  as  in  knee-joint  excision. 
For  a  time  after  excision  the  joint  should 
be  protected  from  weight-bearing  by  the  ap- 
plication of  a  Thomas  splint  or  the  use  of 
crutches. 

SHOULDER. 

Symptoms. — Tuberculous  ostitis  of  the 
shoulder  is  insidious  in  onset,  extremely 
chronic,  and  decided  impairment  in  the  mo- 
tion of  the  joint  is  likely  to  result. 

Pain,  when  present,  is  of  a  dull  aching 
character,  which  is  usually  aggravated  at 
night,  and  is  referred  either  to  the  joint  it- 
self or  to  the  middle  of  the  arm  near  the 
insertion  of  the  deltoid.  In  many  cases  this 
symptom  is  absent  or  very  slight.  Stiffness 
of  the  joint  is  characteristic.  The  patient 
instinctively  holds  the  arm  at  rest,  and  at- 
tempts at  passive  motion  provoke  muscular 

spasm,  and  if  the  attempt  is  persisted  in,  the  humerus  and  scapula 
are  seen  to  move  together.  Early  in  the  disease  a  change  in  contour 
of  the  joint  becomes  apparent,  which  is  due  to  enlargement  of  the 
head  of  the  humerus  as  well  as  to  muscular  atrophy. 

Suppuration  may  occur.  The  subsequent  course  is  slow,  the  result 
depending  on  the  extent  of  the  tuberculous  process,  which  may  termi- 
nate soon  after  evacuation  of  the  pus  or  continue  to  complete  destruc- 
tion of  the  head  of  the  humerus. 

The  possible  results  are:  recovery  with  a  stiff  joint  (ankylosis), 
deformity  and  impaired  muscular  power,  or  entire  destruction  of  the 


FIG.  106. — Treatment  of  Ankle- 
joint  Disease  by  Thomas 
Knee-splint  and  plaster-of- 
Paris  bandage  on  ankle. 


no 


ORTHOPEDIC  SURGERY 


head  of   the   bone ;   and   in   children   arrest   of   development   of   the 
humerus  may  result  later. 

Treatment. — In  tuberculous  ostitis  at  the  shoulder-joint  the  indica- 
tions for  treatment  are  practically  the  same  as  those  presented  in 
other  joints.  Distraction  is  not  indicated  in  disease  of  the  shoulder, 


FIG.   107. —  Disease  of   Right   Shoulder-joint,  Showing  Atrophy  and   Change   in   Outline. 

as,  owing  to  the  laxity  of  the  joint,  the  weight  of  the  dependent  arm, 
if  kept  at  rest,  is  sufficient  to  separate  the  humerus  from  the  opposing 
bone  surface  of  the  scapular  articulation;  but  in  very  painful  cases 
fixation  of  the  joint  by  means  of  a  plaster  bandage  with  the  arm  held 
abducted  or  fixed  on  a  padded  triangular  axillary  pad  may  be  needed. 

Excision  of  the  joint  may  be  necessary  in  adults,  but  is  rarely  indi- 
cated in  children. 

\Yhere  the  joint  is  ankylosed  in  a  position  close  to  the  side,  func- 
tional improvement  will  follow  operative  forcible  abduction  of  the 
arm,  with  after-treatment  securing  fixation  of  the  joint,  with  the  arm 
abducted.  . 

ELBOW. 

Symptoms. — The  disease  may  begin  with  pain,  but  this  is  not 
severe  and  often  is  entirelv  absent.  Limitation  of  extension  of  the 


TUBERCULOUS  DISEASE  OF  THE  ELBOW  in 

forearm  is  a  constant  and  early  symptom,  motion  in  this  direction 
being  distinctly  restricted  when  flexion,  pronation,  and  supination  are 
free.  A  slight  increase  of  surface  temperature  is  usually  found,  but 
its  absence  does  not  exclude  the  disease.  Careful  examination  will 
reveal  a  slight  amount  of  swelling  even  at  this  stage  of  the  affection, 


FIG.   108. — Same   Case   as   Fig.    107.      Showing   limitation   of  abduction   in   attempt   to   raise  both 

elbows. 


shown  by  fulness  and  thickening  on  either  side  of  the  tendon  of  the 
triceps,  and,  looking  at  the  elbow  from  behind,  the  joint  appears 
broader  than  normal.  As  in  other  joints,  wasting  of  muscles  occurs 
rapidly.  As  the  disease  progresses  the  stiffness  increases,  motion  in 
other  directions  is  restricted  and  resisted  by  muscular  spasm,  and  the 
joint  is  generally  held  at  an  obtuse  angle.  Starting  pains  may  be 
added  to  the  other  symptoms,  and  become  the  source  of  great  dis- 
comfort. The  whole  joint  becomes  involved  in  the  swelling,  the 
enlargement  assuming  a  fusiform  shape. 

The  swelling  sometimes  becomes  very  great.  The  skin  may  be- 
come riddled  with  sinuses,  the  tuberculous  infection  attacks  the  soft 
parts,  and  the  whole  elbow  becomes  a  pulpy,  granulating  mass.  This 
occurs  in  neglected  cases  of  elbow  disease  and  also  as  the  result  of 
relapses  after  excision  of  the  joint.  Tuberculosis  of  the  head  of  the 
radius  may  exist,  in  which  case  limitation  of  rotation  and  local  swell- 
ing are  predominant  symptoms. 


ii2  ORTHOPEDIC  SURGERY 

The  prognosis  in  tuberculous  disease  of  the  elbow  is  not  favorable 
for  re-establishment  of  motion,  unless  the  affection  is  treated  at  a  very 
early  stage.  The  joint  is  so  complicated  that  the  disease  involves  a 
large  and  comparatively  widespread  surface  of  synovial  membrane 
before  its  presence  is  discovered. 

Treatment. — In  tuberculous  disease  of  the  elbow  fixation  is  de- 
manded. This  is  best  furnished  by  plaster-of-Paris  or  moulded 
leather.  Excision  is  advisable  in  the  more  severe  cases  in  adults  where 
conservative  treatment  has  failed,  but  it  is  rarely  needed  in  children 
in  tuberculous  ostitis  of  the  elbow. 

WRIST. 

Symptoms. — Tuberculous  disease  is  characterized  by  swelling, 
heat,  and  stiffness.  If  the  disease  is  advanced,  deformity  will  be  added 
to  the  other  signs.  The  hand  may  be  held  flexed  on  the  forearm  at 
an  angle  of  120°  to  130°. 

Treatment. — In  tuberculous  disease  of  the  wrist- joint  fixation  is 
indicated,  and  it  is  most  easily  obtained  by  the  application  of  anterior 
and  posterior  common  wooden  splints  and  carrying  the  arm  in  a  sling. 
Plaster-of-Paris  or  a  moulded  leather  splint  forms  a  more  permanent 
dressing  and  is  equally  comfortable.  Compression  is  a  valuable  addi- 
tion to  the  treatment  in  addition  to  the  usual  mechanical  measures. 

Active  and  passive  congestion,  by  suction,  dry  heat,  and  artificial 
stasis,  is  of  value  in  affections  of  the  knee,  elbow,  ankle,  and  wrist 
in  the  less  acute  stages. 

Excision  of  the  joint  is  rarely  indicated  in  children  in  the  less 
active  stage,  but  may  be  needed  in  adults.  Other  things  being  equal,  a 
loose  joint  entails  less  power  in  the  hands  and  fingers  than  a  stiff  one. 

Here,  as  in  other  excisions,  informal  methods  of  operating  may  be 
necessary  on  account  of  the  situation  of  abscesses  and  sinuses. 

SACRO-ILIAC   DISEASE. 

By  sacro-iliac  disease  is  meant  disease  of  the  sacro-iliac  synchon- 
drosis.  This  affection  is  also  known  as  sacro-coxitis  (Hueter),  sacrar- 
throcace,  and  sacro-coxalgie. 

Disease  of  this  joint  is  a  rare  condition.  It  is  essentially  a  dis- 
ease of  young  adult  life,  being  slightly  more  common  in  men  than 
in  women.  It  occurs  occasionally  in  children. 

Tuberculous  disease  of  the  sacro-iliac  articulation  is  a  rare  affec- 


SACRO-ILIAC  DISEASE  113 

tion  and  extremely  rare  in  children.     When  it.  occurs  it  is  usually 
secondary  to  tuberculous  ostitis  elsewhere. 

The  early  symptoms  are  limp  and  a  peculiar  attitude,  the  patient 
leaning 'away  from  the  affected  side;  there  are  swelling  and  pain  en 
deep  pressure  over  the  region  of  the  sacro-iliac  articulation,  and  some 
limitation  in  motion  of  the  limb,  but  less  than  in  hip  disease.  The 
prognosis  is  unfavorable.  The  treatment  is  the  application  of  a 
plaster  or  leather  belt  and  the  use  of  crutches  when  locomotion  is 
possible. 


CHAPTER  VI. 

INFECTIOUS    OSTEOMYELITIS— INFECTIOUS    SYNOVITIS 

AND    ARTHRITIS. 

INFECTIOUS    OSTEOMYELITIS. 

THIS  process,  primarily  attacking  the  bones  and  at  times  seconda- 
rily affecting  the  joints,  is  the  result  of  an  infection  by  some 
pyogenic  bacterium.  It  attacks  preferably  the  diaphysis  of  the  long 
bones,  generally  near  the  epiphysis,  and  usually  one  bone  only  is  at- 
tacked. If  it  is  confined  to  the  shaft  of  the  bone  the  joints  are  not 
involved,  but  when  it  is  located  near  the  ends  of  the  bone  the  joints 
may  be  invaded. 

Etiology. — The  organisms  found  are  the  usual  pyogenic  bacteria, 
but  the  pneumGcoccus  at  times  is  the  cause  of  a  process  indistinguish- 
able from  that  caused  by  the  streptococcus  or  the  staphylococcus. 
The  typhoid  bacilli  may  cause  ostitis,  and  secondary  infections  with 
other  organisms  have  been  reported.  The  femur,  the  tibia,  and  the 
humerus  are  the  bones  most  commonly  attacked. 

It  occurs  most  commonly  at  or  shortly  after  the  age  of  puberty. 
The  affection  may  arise  in  the  bone  without  evidence  of  disease  in 
other  tissues,  while  at  other  times  it  is  secondary  to  a  local  infection 
in  some  other  part  of  the  body.  The  disease  appears  frequently  after 
trauma,  extreme  fatigue,  and  exposure  to  cold  and  wet ;  it  also  occurs 
secondarily  to  such  diseases  as  typhoid  fever,  scarlet  fever,  etc. 

Pathology. — The  bone  marrow  is  the  part  primarily  attacked, 
and  the  trabecnke  and  cortex  are  at  first  but  slightly  involved.  The 
process  may  spread  extensively  in  the  marrow  before  it  pierces  the 
cortex,  where  it  extends  and  causes  suppuration  between  the  bone 
and  periosteum  and  later  in  the  soft  tissues,  developing  an  abscess 
which  may  evacuate,  with  the  establishment  of  a  sinus  leading  to 
necrosed  bone.  If  the  periosteum  has  been  extensively  separated  from 
the  cortex,  extensive  necrosis  of  the  shaft  follows,  surrounded  by  a 
formation  of  dense  cicatricial  bone.  As  a  rule  the  process  does  not 
extend  to  the  epiphysis,  but  there  may  be  a  complete  destruction  of  the 
epiphyseal  line  and  a  separation  of  the  epiphysis.  Deformities  may  de- 

114 


INFECTIOUS  OSTEOMYELITIS 


FIG.   109. — Cavity  from  Bone  Abscess. 

the  early  stage  the  a'-ray  does  not 


velop  as  a  result  of  the  destructive 
changes  in  the  soft  parts  adjacent 
to  the  joint,  which  cause  impair- 
ment of  motion,  ankylosis,  and 
displacement  of  joint  surfaces. 

Symptoms. — T  h  e  affection 
frequently  begins  suddenly  with 
severe  general  disturbances,  ac- 
companied by  pain  in  the  affected 
bone;  if  in  the  vicinity  of  a  joint 
it  is  held  rigid  on  account  of  the 
pain.  At  other  times  the  attack 
is  much  less  severe,  the  general 
symptoms  being  those  of  a  moder- 
ate general  infection.  In  addition 
to  the  pain  there  are  present  swell- 
ing and  tenderness  of  the  parts 
about  the  affected  bone,  elevation 
of  temperature  of  a  greater  or 
less  degree,  increase  of  pulse,  and 
symptoms  of  sepsis  in  a  degree 
varying  with  the  severity  of  the 
case.  Increased  leucocytosis  is 
present.  The  stage  of  onset,  es- 
pecially when  of  moderate  sever- 
ity, may  be  overlooked  by  the 
attendants  of  the  patient,  whose 
attention  is  centred  on  the  severity 
of  the  general  symptoms.  If  the 
disease  is  left  unrelieved  the  con- 
dition becomes  rapidly  worse,  in 
the  severer  cases  markedly  septic 
symptoms  appearing. 

Diagnosis.  — The  diagnostic 
signs  of  the  condition  are  rapid 
onset,  marked  rise  of  tempera- 
ture, symptoms  of  sepsis,  in- 
creased leucocytosis,  and  signs  of 
a  severe  inflammatory  process 
over  one  of  the  long  bones.  In 
afford  a  reliable  means  of  diagnosis. 


ORTHOPEDIC.  SURGERY 


Prognosis. — In  the  severer  types  of  this  affection  the  condition 
is  grave  and  the  danger  of  septicaemia  is  considerable.  The  prognosis 
depends  in  a  measure  on  the  stage  of  the  infection  at  which  operative 
relief  is  afforded.  In  the  less  severe  cases  a  stage  oi  extreme  pain 
persisting  for  some  weeks  is  followed  by  abscess  development  with 
necrosis  and  the  establishment  of  sinuses.  \Yhen  the  affection  is  near 
the  joint  in  young  children  the  liability  to  dislocation  and  separation 
of  the  epiphysis  is  to  be  borne  in 
mind.  In  young  infants,  who  are 
frequently  affected,  the  prognosis 
is  serious,  and  prompt  opera- 
tion offers  the  best  chance.  The 
motion  of  the  joint  is  not  neces- 
sarily lost  where  early  opera- 
tion is  undertaken,  but  ankylosis 
is  a  common  outcome  of  the  se- 
vere grades  of  the  condition. 

Treatment. — The  treatment 
varies  with  the  stage  of  the  dis- 
ease. In  the  acute  stage  if  the 
symptoms  are  at  all  severe  the  in- 
dication is  to  cut  down  upon  the 
diseased  area  and  to  establish 
drainage.  As  the  focus  is  in  the 
marrow,  the  cortex  oi  the  bone  is 
to  be  opened  until  the  marrow  is 
reached  and  drainage  established. 
\\here  exact  localization  is  not 
possible  the  bone  can  be  trephined 
in  the  diaphysis  near  the  epi- 

physeal  line.  The  marrow  should  not  be  curetted.  If  the  symp- 
toms are  slight  it  may  be  safe  to  delay  active  interference,  but  judg- 
ment should  favor  incision  and  drainage  in  all  doubtful  cases. 

In  the  subacute  stage  it  is  desirable  to  remove  the  necrotic  area 
to  establish  the  regeneration  which  takes  place  through  the  periosteum. 
The  periosteum  should  be  separated  from  the  bone,  and  in  cases 
with  extensive  disease  the  diseased  shaft  removed  and  the  inner  edges 
of  the  periosteum  placed  in  apposition,  to  favor  the  formation  of  new 
bone.  The  removal  of  this  necrotic  portion  should  not  be  attempted 
until  the  acute  stage  has  passed,  usually  about  two  months  after  the 
first  onset  of  the  disease. 


FIG.    1 10. — Acute    Infectious    Osteomyelitis    of 
Tibia    Involving  Knee-joint. 


INFECTIOUS  OSTEOMYELITIS 


117 


In  the  chronic  stage  the  treatment  involves  the  consideration  not 
only  of  the  removal  of  the  sequestrum,  but  the  filling  of  the  remaining 
cavity  with  normal  bone.  As  the  cavity  is  surrounded  by  thick,  hard 
bone  with  little  vascularity,  it  does  not  readily  develop  new,  healthy 
bone  growth.1  The  removal  of  the  shaft  as  well  as  the  sequestrum 
and  stitching  the  surfaces  of  the  uppermost  sides  together  is  indicated 
in  such  cases.  The  experience  of  the  writers  has  not  been  favorable 


FIG.  in.— Acute  Osteomyelitis  of  the  Knee-joint. 

to  the  use  of  the  iodoform  wax  bone  plug  in  such  bone  cavities  and 
they  prefer  to  allow  the  cavity  to  fill  from  clot. 

\Yhen  the  joint  is  involved,  in  the  acute  stage,  drainage  should 
be  established  as  soon  as  possible  by  free  incisions.  In  the  subacute 
stage  where  no  sinus  has  been  established  the  joint  will  need  fixation 
and  protection  to  check  the  progress  of  the  disease  and  to  prevent 
deformity.  In  the  chronic  stage  with  sinuses  and  sequestra,  the  treat- 
ment consists  of  the  thorough  drainage  of  bone  with  the  free  removal 
of  the  hardened  bone.  If  the  cavity  necessary  for  complete  drainage 
is  a  large  one,  it  can  be  left  to  fill  in  with  granulation  or  can  be  covered 
in  with  a  periosteal  flap. 

The  treatment  of  the  deformities  following  infectious  osteomy- 
elitis is  similar  to  that  of  the  deformities  following  tuberculous  ostitis. 

SPINE. 

Acute  Osteomyelitis. — The  spine  is  not  commonly  attacked  by 
this  disease.  When  it  does  occur  the  most  common  age  of  onset  is 
from  six  to  fifteen,  but  younger  children  and  adults  are  not  exempt. 

journal  of  Amer.  Med.  Assn.,  February  13th,  1904. 


ii8  ORTHOPEDIC  SURGERY 

The  process  may  attack  either  the  vertebral  arches  or  the  bodies,  and 
is  of  the  same  general  character  as  osteomyelitis  elsewhere,  modified 
by  the  peculiar  structure  of  the  vertebral  column.  The  lumbar  region 
is  most  frequently  affected,  but  no  part  of  the  spine  is  exempt. 

The  symptoms  are  stiffness,  tenderness  and  pain,  high  fever,  and 
much  constitutional  disturbance  as  described  above.  Abscess  occurs 
in  practically  all  cases  and  the  tissues  around  the  abscess  become 
cedematous.  Although  posterior  abscesses  are  accessible,  anterior 
abscesses  are  almost  impossible  to  locate.  Paralysis  occurs  in  about 
one-third  of  the  cases. 

Deformity  of  the  spine  is  not  of  frequent  occurrence,  because, 
although  the  process  is  rapidly  destructive,  the  new  formation  of  bone 
is  rapid  and  the  severity  of  the  disease  necessitates  recumbency.  The 
mortality  is  high  in  the  more  severe  cases. 

Direct  incision  to  the  bone,  furnishing  drainage,  is  indicated  as 
soon  as  is  possible.  During  convalescence  the  spine  should  be  sup- 
ported as  in  Pott's  disease. 

Typhoid  Spine. — In  the  later  stages  of  typhoid  fever,  an  acute, 
painful  condition  of  the  spine,  presenting  symptoms  similar  to  those 
of  very  acute  Pott's  disease,  occasionally  is  seen.  Deformity  is  not 
the  rule  and  when  it  occurs  is  small  in  extent,  and  thickening  of  por- 
tions of  the  spinal  column  may  be  felt  on  palpation.  The  prognosis 
for  ultimate  recovery  is  good  and  the  treatment  does  not  differ  from 
that  of  acute  Pott's  disease. 

HIP. 

Acute  Osteomyelitis. — This  location  of  osteomyelitis  is  compara- 
tively frequent,  and  the  process  may  be  acute  and  rapidly  destructive, 
or  slower  and  less  acute.  In  infants  it  is  rather  a  violent  process, 
accompanied  by  high  fever  and  much  swelling  about  the  hip,  and  pain 
and  constitutional  disturbance  are  marked.  Flexion  of  the  limb  and 
muscular  spasm  are  pronounced  and  abscess  occurs  in  most,  if  not  in 
all  cases.  The  process  may  cause  separation  of  the  epiphysis  of  the 
femur,  destruction  of  the  head  of  the  femur,  or  dislocation  of  the  hip 
by  destruction  of  the  capsule  without  destruction  of  the  head.  In 
each  of  these  conditions  the  hip  is  found  completely  dislocated  with 
perhaps  grating  in  the  joint,  and  this  is  spoken  of  as  floating 
pseudoarthrosis  or  pscndoarthrose  flottante.1  Extensive  osteomyelitis 
of  the  femur  may  remain  after  the  hip  symptoms  have  been  relieved 
by  operation. 

1Ducroquet  et  Besangon  :  Presse  M£d  ,  No.  15,  1903. 


INFECTIOUS  OSTEOMYELITIS  119 

In  older  children  the  process  is  less  violent  and  bears  more  resem- 
blance to  tuberculosis  of  the  hip  in  its  clinical  aspect,  except  that  the 
symptoms,  are,  as  a  rule,  more  acute  and  severe.  Shortening  may 
occur  rapidly  and  abscess  is  practically  universal  in  the  severer  cases. 
In  some  cases  the  affection  is  less  acute,  and  in  these  the  diagnosis 
from  tuberculosis  often  cannot  be  made  until  the  abscess  is  opened 
and  a  culture  made  from  its  contents. 

The  treatment  of  the  disease  does  not  differ  from  that  of  osteomye- 
litis in  other  joints.  The  hip-joint,  however,  may  require  traction 
or  protection  after  operation. 

In  other  joints  the  affection  presents  no  peculiar  characteristics. 

ACUTE  ARTHRITIS  OF  INFANTS. 

This  condition  is  now  identified  as  a  variety  of  pyogenic  joint  in- 
fection, the  exact  pathological  history  of  which  is  not  known,  but 
which  is  generally  secondary  to  acute  osteomyelitis.  The  onset  is  se- 
vere and  is  characterized  by  the  same  symptoms  described  above  in  con- 
nection with  acute  osteomyelitis  involving  the  joints.  Death  may 
occur  from  septicaemia,  and  the  prognosis  depends  more  upon  the  per- 
formance of  an  early  effective  operation  than  on  anything  else.  Treat- 
ment should  consist  in  free  incision  and  flushing  out  of  the  affected 
joint  with  free  drainage. 

INFECTIOUS    SYNOVITIS     AND    ARTHRITIS. 

An  inflammation  of  the  joints,  which  may  be  acute  or  chronic, 
serous  or  purulent,  may  occur  in  connection  with  acute  infectious 
diseases. 

Etiology. — The  lesions  which  occur  are  to  be  attributed  to  the 
presence  in  the  joints  of  micro-organisms  or  their  products,  and 
the  organisms  found  in  the  joints  are  either  the  staphylococcus,  the 
streptococcus,  or  the  organism  peculiar  to  the  primary  disease.  An 
affection  of  the  joints  of  a  similar  character  is  seen  at  times  where 
no  antecedent  infectious  disease  can  be  identified.  In  the  same  con- 
nection must  be  mentioned  pyogenic  infection  of  the  joints  from 
wounds  and  similar  outside  sources. 

In  consequence  of  some  of  the  above-mentioned  infections  there 
arises  a  chronic  joint  affection  of  another  type,  not  to  be  distinguished 
clinically  from  arthritis  deformans.  It  will  be  considered  in  that  con- 
nection. 

Pathology. — The  affection  is  most  often  manifested  by  an  acute 


120  ORTHOPEDIC  SURGERY 

serous,  sero-purulent,  or  purulent  inflammation  of  the  joint.  The 
process  is  generally  most  evident  in  the  synovial  membrane,  and, 
although  bony  involvement  by  extension  may  occur,  it  is  not  the  rule. 
In  purulent  cases  there  is  suppuration  of  the  synovial  membrane  with 
loss  of  epithelium,  and  in  severe  cases  the  formation  of  granulation 
tissue,  fibrous  degeneration,  or  even  necrosis  of  the  cartilage  and 
damage  to  the  ends  of  the  bones  and  destruction  of  the  ligaments. 
Spontaneous  luxations  may  occur  and  ankylosis  must  result  in  the 
severest  cases.  In  a  great  part  of  the  cases,  however,  the  local  process 
runs  its  course  without  great  local  damage,  for  early  incision  is  usually 
resorted  to  before  the  process  has  accomplished  extensive  destruction. 
Less  commonly  these  processes  are  chronic  or  subacute. 

Symptoms. — The  symptoms  vary  according  to  the  grade  and  char- 
acter of  the  infection,  from  those  of  a  simple  synovitis  to  those  of  a 
severe  suppurative  process. 

Treatment. — In  the  milder  crises  the  treatment  is  that  of  synovitis, 
i.e.,  fixation,  compression,  hot  or  cold  applications  and  dry  heat.  In 
suppurative  cases  the  joint  should  be  freely  opened,  washed  out,  and 
drained  as  soon  as  the  existence  of  suppuration  is  recognized. 

The  only  modification  of  the  usual  free  incisions  in  general  use 
is  to  be  found  at  the  knee-joint,  in  which,  in  severe  cases,  it  is  advisable 
to  make  an  extensive  U-shaped  incision,  cut  the  patella  tendon  across, 
and  fix  the  knee  in  a  flexed  position.  In  this  way  the  joint  is  thor- 
oughly drained.  The  patella  tendon  is  sutured  when  repair  is  estab- 
lished. 

GOXORRHOZAL   ARTHRITIS. 

Gonorrhceal  synovitis  or  arthritis,  and  gonorrhceal  rheumatism  are 
the  names  most  commonly  applied  to  an  inflammation  of  the  joints 
occurring  in  the  later  stages  of  gonorrhoea.  This  inflammation  is 
acute  or  chronic,  and  is  most  often  ivb-prticular. 

Varieties. — The  commonest  forms  of  inflammation  are  as  follows: 
Arthralgia,  without  definite  lesions;  acute  synovitis;  periarticular  in- 
flammation; tenosynovitis;  and  chronic  synovitis. 

Pathology. — The  effusion,  if  serous,  is  generally  thick  and  may 
contain  clots  of  fibrin  or  may  be  colored  by  blood.  In  the  severer 
cases  the  effusion  is  purulent  or  sero-purulent  and  the  joint  changes 
may  not  differ  from  those  described  in  the  arthritis  due  to  pyaemic 
processes.  Such  a  process  shows  little  tendency  to  involve  bone  or 
cartilage,  being  essentially  synovial.  The  inflammation  shows  the 
same  tendency  toward  fibrous  hyperplasia  in  the  joints  that  it  does  in 


INFECTIOUS  ARTHRITIS  121 

the  urethra,  which,  of  course,  tends  to  impair  joint  motion  and 
ankylosis  is  to  be  feared. 

Etiology. — The  affection  has  been  demonstrated  to  be  due  to  the 
gonococcus,  which  are  found  in  the  joint  effusion  in  many  cases,  espe- 
cially the  acute  ones.  They  may,  however,  not  be  found  in  the 
effusion  or  in  sections  of  the  synovial  membrane.  A  mixed  infection 
with  pyogenic  organisms  may  be  found,  or,  rarely,  pyogenic  organisms 
alone  may  be  found  in  the  joint  fluid.  Suppuration  of  the  joint  is 
not  necessarily  associated  with  mixed  infection. 

Men  are  much  more  frequently  affected  than  women.  The  com- 
plication rarely,  if  ever,  occurs  before  the  third  week  of  the  disease, 
and  occurs  in  about  two  per  cent  of  all  cases.  Involvement  of  the 
joints, may  occur  after  the  passage  of  a  sound  into  the  urethra,  in 
the  vulvovaginitis  of  little  girls,  and  in  the  gonorrhoeal  ophthalmia  of 
babies. 

The  prognosis  can  hardly  be  formulated.  The  affection  is  always 
serious  and  generally  slow  in  progress  and  resistant  to  medication. 
In  the  acute  stages  suppuration  is  to  be  feared,  and  impairment  of 
motion,  perhaps  ankylosis,  is  not  unlikely  to  result.  Simple  cases  often 
recover  after  a  long  time  with  practically  normal  motion. 

Treatment. — In  the  acute  stage  the  affection  should  be  treated  like 
other  forms  of  synovitis,  passive  hypersemia,  radiant  heat,  and 
similar  measures  being  particularly  applicable.  Suppuration  de- 
mands incision  and  drainage.  Convalescent  cases  should  be  treated 
as  if  convalescent  from  ordinary  synovitis,  only  with  greater  care. 
The  use  of  the  anti-gonococcus  vaccine  is  desirable  before  proceeding 
to  operative  measures  and  in  obstinate  cases. 

Obstinate  and  persistent  chronic  synovitis,  if  in  the  hip,  should 
be  treated  by  protection,  and  perhaps  traction  by  apparatus.  Fixation 
by  plaster  bandages  is  to  be  used  if  the  joint  is  painful.  More  acces- 
sible joints  are  best  treated  by  free  incision  and  flushing  out  with  hot 
sterile  water  or  hot  weak  corrosive  solution  in  obstinate  cases.  Drain- 
age for  a  few  days  should  be  kept  up  by  strips  of  gauze,  and  the  joint 
should  be  washed  out  daily  in  severe  cases. 

If  operation  is  not  practicable  the  ordinary  measures  in  use  for 
the  treatment  of  chronic  synovitis  are  to  be  used. 


CHAPTER  VII. 

ARTHRITIS    DEFORMANS. 

ARTHRITIS  DEFORMANS  is  a  chronic,  non-suppurative  affection, 
which  attacks  the  joints,  at  times  crippling  and  deforming  them. 

It  is  known  by  a  multiplicity  of  names,  of  which  the  following  are 
the  principal  ones:  Arthritis  deformans,  rheumatic  gout,  chronic 
rheumatic  arthritis,  osteoarthritis,  rheumatoid  arthritis,  dry  arthritis, 
and  chronic  articular  rheumatism.  The  name  arthritis  deformans, 
proposed  by  Virchow,  is  used  here,  as  it  is  descriptive  and  involves  no 
etiological  or  pathological  theory. 

The  disease  is  common,  and  varies  in  its  manifestations,  as  may 
be  inferred  from  the  various  names  which  have  been  assigned  to  it. 
Some  confusion  has  arisen  in  the  minds  of  practitioners  from  the 
terminology,  which  has  associated  the  affection  with  rheumatism,  the 
disease  having  been  called  chronic  rheumatism,  chronic  rheumatoid 
arthritis,  etc. 

Many  observers  have  noted  that  under  the  general  head  of  ar- 
ritis  deformans  two  different  clinically  associated  symptoms  are  placed. 
Investigations,  especially  the  thorough  and  masterly  research  of 
Nichols  and  Richardson,1  have  demonstrated  the  relation  of  the  char- 
acteristic symptoms  to  two  pathologically  distinct  groups. 

1.  Proliferative  Arthritis. — Characterized    by     primary     prolifer- 
ative  changes  in  the  perichondrium  and  synovial  membrane  tending 
to  ankylosis. 

2.  Degenerative  arthritis. — With  a  primary  degeneration  of  the 
joint  cartilage  resulting  in  joint  stiffening. 

PROLIFERATIVE  ARTHRITIS  (ANKYLOSI:STG  ARTHRITIS). — In  this 
form  proliferations  develop  on  the  surface  of  the  synovial  mem- 
brane near  the  cartilage  and  on  the  perichondrium  of  the  articular 
cavity,  combined  in  many  cases  with  synchronous  proliferations  of  the 
connective  tissue  and  of  the  endosteum  in  the  epiphyseal  marrow  di- 
rectly below  the  joint  cartilage.  As  a  result  of  these  changes  a  pannus 
is  formed  which  destroys  the  cartilage.  In  many  instances  also  a  layer 
of  connective  tissue  grows  from  the  part  of  cartilage  which  is  not  un- 
1  Journal  of  Medical  Research,  1910. 


ARTHRITIS  DEFORMANS  123 

dermined  by  the  pannus.  Changes  in  the  capsule  and  synovial  mem- 
brane also  take  place,  consisting  of  the  development  of  granulation  tis- 
sue with  fibrous  thickening.  The  joint  is  gradually  disorganized,  even- 
tually terminating  in  ankylosis.  Suppuration  does  not  take  place,  and 
the  process  is  not  acute,  although  there  may  be  acute  stages.  There 


FIG.  112. — Arthritis  Deformans  of  Knee-joint. 

may  be  long  remissions;  the  damage  to  the  joint  involved  varies  and 
the  process  may  be  arrested  at  any  stage.  The  periarticular  tissues 
may  be  swollen,  but  without  heat  or  tenderness.  Later  the  periarticu- 
lar oedema  disappears  in  part  and  a  shrunken  condition  of  portions 
of  the  tissues  may  eventually  result.  Disability,  loss  of  motion,  dis- 
tortions, and  partial  dislocations  finally  result.  As  a  rule  there  is 
an  absence  of  peripheral  exostosis.  The  bones  of  the  affected  joint 
show  an  increased  permeability  to  the  .r-ray,  probably  from  an  absorp- 
tion of  lime  salts  from  disease,  this  occurring  without  histological 


124 


ORTHOPEDIC  SURGERY 


change.  This  form  of  arthritis  attacks  the  middle-aged  and  the  young, 
even  the  very  young,  but  not  the  aged.  The  affection  involves  a 
single  joint  at  first,  but  gradually  extends  to  other  joints,  as  it  is 
characteristically  polyarticular.  In  the  severe  cases  a  pitiable  condi- 
tion of  stiffening  distortion  results,  with  ankylosis  of  all  the  impor- 
tant joints.  The  disease  is  extremely  chronic.  Periods  of  sensitive- 
ness on  the  slightest  jar  or  motion 
are  followed  by  a  painful  stage 
with  great  disability 

Etiology. — Little  is  known  of 
the  etiology  of  the  affection. 
Adequate  proof  that  it  is  a  germ- 
caused  disease  is  wanting,  al- 
though the  affection  in  some  in- 
stances follows  gonorrhoea,  but  in 
the  majority  of  cases  no  germ 
causation  is  formed.  The  exist- 
ence of  some  soluble  irritant  as 
yet  unknown  is  often  assumed  as 
an  exciting  cause. 

The  prognosis  is,  in  the  mid- 
dle-aged, extremely  unfavorable, 
and  very  doubtful  in  the  young,  in 
cases  involving  many  joints,  but 
where  in  the  young  no  more  than 
one  or  two  joints  are  affected,  an 
arrest  of  the  process  may  take 
place. 

A  diagnosis  of  the  affection  is 

based  on  its  chronic  character,  the  fact  that  it  is  polyarticular  and 
non-suppurative  with  a  different  clinical  history  from  that  usually  seen 
in  the  ordinary  tuberculous  joint  disease. 

DEGENERATIVE  ARTHRITIS  (STIFFENING  ARTHRITIS). — In  this 
group  the  primary  change  is  the  fibrillation  and  softening  with  erosion 
of  a  portion  of  the  joint  cartilage.  The  underlying  bone  becomes 
exposed  so  that  the  joint  surface  articulates  with  a  bony  and  not 
cartilaginous  surface,  and  with  bone  which  becomes  abnormally  hard 
and  is  eburnated.  The  changes  are  not  uniform  throughout  the  joint, 
irregular  growth  of  bone  and  cartilage  takes  place,  often  with  erosion 
in  one  place  and  compensating  overgrowth  in  another.  There  is 
increased  perichondrial  activity  and  new  formation  of  cartilage  and 


FIG.  113. — Hand  in  Arthritis  Deformans,  Show- 
ing the  Enlargement  at  the  Middle  of  the 
Middle  Finger.  (By  the  courtesy  of  the  De- 
partment of  Surgical  Pathology  of  the  Har- 
vard Medical  School.) 


FIG.  114. — Double  Hallux  Valgus  and  Hammer 
Toes.     Associated  with  arthritis  deformans. 


ARTHRITIS  DEFORMANS  125 

bone,  with  irregular  increase  circumferentially.  The  joint  is  irregu- 
larly enlarged;  there  is  periarticular  thickening,  but,  as  a  rule,  the 
synovial  membrane  is  normal,  except  at  the  periphery  of  the  joint 
there  may  be  pedunculated  growth  of  connective  tissue,  which  may 

become  cedematous  or  infiltrated 
with  fat,  developing  the  so-called 
lipoma  arborescens.  There  may 
be  in  these  fibrous  projections 
cartilage  and  bone  growth,  the 
peduncular  attachment  may  be 
tern,  resulting  in  cartilaginous 
bodies,  often  partly  ossified, 
which  remain  free  in  the  joint 
cavity,  the  so-called  rice  bodies 
or  joint  mice. 

In  the  marrow  various 
changes  may  occur.  Fatty  and 
mucoid  degeneration  may  follow 
the  destruction  of  the  cartilage, 
giving  the  bone  greater  trans- 

lucency  to  A'-ray  illumination,  and  irregular  formation  of  bone  may 
take  place  in  the  periosteum,  the  fibrous  attachment  of  the  capsule, 
the  ligaments,  and  the  insertion  of  the  periarticular  muscles.  The 
changes  above  named  constitute  the  chief  form  of  distortion  as  seen 
clinically.  The  distortion  of  the  joint  is  also  the  result  of  relaxation 
of  the  capsule  in  places,  with  contraction  in  other  places,  and  to  the 
pull  of  the  muscles  from  the  muscular  spasm  reflex  to  joint  irrita- 
tion. It  must  be  remembered  that  tuberculous  degeneration  of 
chronically  enlarged  synovial  villi  may  occur,  but  it  is  to  be  regarded 
as  a  pathological  process  distinct  from  arthritis  deformans. 

The  muscles  controlling  the  joint  become  changed  and  undergo 
atrophy  and  fibrous  degeneration.  The  periarticular  subcutaneous 
tissue  and  the  fascia  in  the  vicinity  of  the  joint  are  likely  to  become 
involved  in  the  process,  and  are  found  to  be  cedematous,  and  hyper- 
plasia  and  permanent  thickening  may  occur.  The  synovial  fluid  in 
some  instances,  especially  in  the  more  acute  stages,  is  increased  in 
amount  and  becomes  slightly  turbid.  Acute  enlargement  of  the 
lymphatic  nodes  and  the  spleen  is  not  often  seen  in  the  arthritis 
deformans  of  adults.  The  blood  is  normal  in  most  cases,  as  to  the 
percentage  of  haemoglobin,  the  leucocyte  count,  and  the  differential 
count.  The  urine  shows  no  characteristic  changes. 


126  ORTHOPEDIC  SURGERY 

Complications  are  not  uncommon  in  advanced  cases,  from  en- 
largement of  the  heart,  chronic  nephritis,  and  the  various  manifesta- 
tions of  arteriosclerosis. 

Etiology — As   the  affection   is   almost   entirely   confined   to  the 


FIG.    115. — Enlargement    of   Knees    and    Ankles    from    Arthritis    Deformans   in    a    Child    of   Ten. 

Disease  of  long  duration. 


physiologically  old,  it  may  be  classed  generally  with  senile  changes, 
e.g.,  arteriosclerosis  or  fibrous  degenerations  elsewhere.  A  toxin 
developed  in  the  intestine  from  imperfect  intestinal  activity  is  sug- 
gested as  a  probable  cause,  but  for  a  satisfactory  understanding  of 
the  subject,  further  investigation  is  demanded.  In  certain  cases  in- 


ARTHRITIS  DEFORMANS  127 

jury  is  ascribed  as  the  exciting  cause,  but  in  a  majority  of  cases  the 
disease  develops  without  obvious  traumatic  origin.  Some  disturb- 
ance of  metabolism  is  apparently  connected  with  many  of  the 
cases. 

In  both  forms  of  arthritis  deformans  the  possibility  of  absorp- 
tion from  a  pyogenic  focus  should  be  borne  in  mind,  as,  for  example, 
from  the  teeth,  tonsils,  and  uterus,  and  if  such  a  source  of  absorption 
is  found  it  should  be  removed. 

A  similar  condition  is  seen  in  the  knee  and  hip  and  in  some  cases 
of  tabes  dorsalis,  where  undoubted  degeneration  of  the  cord  exists, 
but  the  relation  of  these  Charcot  joints  to  the  condition  of  nerve 
degeneration  is  not  understood,  and  there  is  no  reason  to  assume, 
in  the  ordinary  case  of  degenerative  arthritis,  the  existence  of  any 
change  in  the  cord.  The  affection  is  monp.rticular,  or  attacks 
not  more  than  two  joints,  except  in  the  hands,  where  many 
of  the  terminal  phalanges  may  be  affected,  forming  what  is 
known  as  Heberden's  nodes.  This  form  is  more  common  in 
women. 

The  most  constant  symptom  is  impaired  motion;  the  joint  be- 
comes stiffened,  the  stiffening  being  at  first  more  marked  after  rest, 
the  stiffness  disappearing  with  use.  The  limitation  of  motion,  how- 
ever, increases  gradually,  until  complete  stiffness  may  result,  with 
deformity  and  partial  dislocation;  there  is  never,  however,  a  true 
ankylosis.  There  may  be  little  or  no  pain,  except  the  pain  which 
comes  from  the  distorted  use  of  a  limb. 

Symptoms. — The  onset  of  the  affection  is,  as  a  rule,  gradual,  and 
the  early  symptoms  are  most  often  a  gradually  increasing  lack  of 
flexibility  in  certain  joints,  which  is  followed  by  occasional  pain  after 
unusual  exertion.  Cracking  of  the  joint  is  felt,  which  may  be  heard 
with  the  stethoscope.  The  stiffness  of  the  joint  when  overused  in  the 
early  stages  is  most  evident  after  a  period  of  rest,  and  in  this  early 
stage  it  may  be  a  long  period  before  the  disease  is  recognized.  In  a 
certain  number  of  cases  during  this  early  stage,  before  the  marked 
appearance  of  characteristic  changes,  a  slight  elevation  of  tempera- 
ture, and  an  increase  of  pulse  may  be  observed,  which  may  persist 
for  some  time.  In  addition  to  the  general  discomfort,  there 
may  be  also  present  impairment  of  the  general  condition,  and  the 
gradual  increase  of  the  symptoms  is  accentuated  at  times  by  slight 
acute  attacks.  In  other  cases  the  invasion  is  somewhat  acute,  so 
that  the  affection  resembles  what  is  ordinarily  known  as  "  acute 
rheumatism." 


128 


ORTHOPEDIC  SURGERY 


Swelling. — The  swelling  varies  greatly  both  in  amount  and  in  its 
location.  In  the  milder  cases  of  the  most  chronic  type  at  an  early 
stage,  little  swelling  is  present,  but  swelling  of  the  synovial  tissues, 
with  perhaps  synovial  effusion,  is  likely  to  be  recognized  at  a  com- 
paratively early  stage  of  the  affection,  and  is  of  importance.  Later 
there  occurs  a  fusiform  swelling,  consisting  of  cedematous  periarticu- 
lar  tissues,  the  capsule,  and  the  ligaments,  along  with  some  inflamma- 
tion of  the  svnovial  membrane. 


FIG.     116. — Hand    in    Arthritis    Defer- 
mans  in  a   Child   Ten  Years   Old. 


FIG.  117. — Arthritis  Deformans  of  Long 
Standing  (Heberden's  Nodes).  Marked 
enlargement  of  the  distal  phalangeal 
joints.  (By  the  courtesy  of  the  Depart- 
ment of  Surgical  Pathology  of  the 
Harvard  Medical  School.) 


Stiffness. — The  limitation  of  motion  in  affected  joints  is  due 
partly  to  the  mechanical  obstructions  to  motion  produced  by  the 
pathological  process,  and  partly  to  muscular  spasm,  which,  however, 
is  a  much  less  prominent  factor  than  in  tuberculous  disease,  except 
when  the  process  has  become  extensive. 

Distortion. — This  swelling  may  diminish,  leaving  the  joint  dis- 
torted by  the  muscular  spasm,  the  cicatricial  contraction  of  some 


ARTHRITIS  DEFORMANS 


129 


structures,  and  the  relaxation  of  others,  along  with  the  periarticular 
thickening  of  the  periosteum  and  other  tissues  which  have  become 
the  seat  of  bony  deposit. 

Skin  and  Fascia. — The  subcutaneous  tissue  and  the  fascia  may 
undergo  changes,  which  are  characterized  at  first  by  swelling,  which 
may  be  followed  by  thickening  and  contraction.  In  certain  places  in 
the  fascia,  nodules  may  be  felt,  which  may  be  the  occasion  of  dis- 
comfort when  they  occur  in  the  plantar  fascia,  which  is  occasionally 
the  case. 

Diagnosis. — When  an  adult  is  affected  with  a  chronic  progressive 
affection  of  several  of  the  joints,  accompanied  by  swelling,  slight 
pain,  absence  of  suppuration,  with  an  increasing  deformity  and  an 


FIG.  118. — Arthritis  Deformans  in  a  Child  of  Ten,  of  Long  Duration.  Most  of  the  joints  af- 
fected. Showing  enlargement  of  elbows,  wrists,  and  ankles,  and  flexion  deformity  of 
knees. 


enlargement,  partly  of  bone  and  partly  of  the  capsule,  diagnosis  of 
arthritis  deformans  is  easily  made.  In  the  less  developed  cases,  in 
which  the  affection  is  monarticular  or  occurs  in  children,  it  is  at  times 
difficult,  if  not  impossible,  without  a  careful  observation  of  the  case, 
to  determine  whether  the  case  is  tuberculous  or  not.  A  diagnosis 
can  be  made  by  incision  of  the  joint  and  inoculation  experiments.  In 
children,  as  well  as  in  adults,  chronic  non-suppurative  polyarticular 
affections  are  more  probably  non-tuberculous. 

It  goes  without  saying  that  an  early  diagnosis  is  of  importance 
in  order  that  the  patient  may  be  placed  under  proper  conditions  before 
the  disease  has  made  great  progress. 

Prognosis. — The  disease  is  one  of  slow  development  and  slow  in- 
crease, with  prolonged  remissions  and  arrest  at  any  stage. 

Treatment. — For  a  consideration  of  the  general  treatment  of 
arthritis  deformans,  the  reader  must  be  referred  to  treatises  dealing 


1 30  ORTHOPEDIC  SURGERY 

with  questions  of  metabolism  and  dietetics.  Until  the  etiology  of  the 
different  groups  is  better  understood  further  investigation  is  needed, 
before  the  surgeon  can  find  definite  guidance  as  to  general  thera- 
peutics of  this  class  of  affections.  At  present  it  is  known  that  especial 
attention  should  be  paid  to  the  conditions  affecting  health.  In  the 
degenerative  form  it  is  especially  important  to  promote  normal  ac- 
tivity of  the  larger  intestines,  and  to  prevent  intestinal  ptosis,  as  well 
as  to  furnish  such  a  diet  as  will  check  or  prevent  fermentation  in 
the  colon  and  sigmoid  flexure.  The  judicious  and  occasional  use  of 
cathartics,  enemata,  and  a  moderate  diet,  which  has  been  found  suited 
to  the  individual  case,  and  regular  exercise  promoting  perspiration 
are  important.  The  diet  for  the  physiologically  old  should  differ  in 
quantity  and  character  from  that  of  the  vigorous.  Lactic  acid  fer- 
mented milk  is  advisable  where  absorption  from  intestinal  fermenta- 
tion is  suspected.  A  search  for  a  pycgenic  focus  should  be  made, 
and  if  a  focus  is  found,  a  bacterial  vaccine  may  possibly  be  of 
use. 

LOCAL  TREATMENT. — The  object  of  local  treatment  is  to  promote 
the  circulation  and  to  stimulate  the  tissues  around  the  joints,  which  are 
undergoing  a  process  of  change,  which  must  be  regarded  as  a  degenera- 
tion rather  than  an  inflammation. 

Rest. — \Yhen  the  joints  are  in  an  irritated  condition,  as  indicated 
by  pain,  tenderness,  or  discomfort  during  and  after  motion,  restriction 
of  use  is  for  a  time  advisable.  This  can  be  furnished  by  one  of  the 
mechanical  appliances  described  for  preventing  joint  motion  in  tuber- 
culous diseases  of  the  joints  or  by  the  application  of  a  removable 
plaster  or  other  support.  Such  restriction  of  joint  motion  is  to  be 
employed  for  as  short  a  time  as  possible  and  to  be  discontinued  as 
soon  as  the  acute  stage  is  past. 

Exercises. — The  principle  of  treatment  is  that  the  joints  should  be 
used  within  the  arc  of  their  possible  motion  freely,  but  that  strain, 
violence,  and  excessive  use  should  be  avoided.  Exercises  for  this 
purpose  can  be  given  in  the  form  of  passive  manual  manipulation  or 
by  the  aid  of  such  mechanical  appliances  as  have  been  devised  for  the 
purpose  of  moving  the  joint  without  the  use  of  the  muscles,  such  as 
the  Zander  apparatus  and  others.  As  the  joints  improve,  carefully 
prescribed  active  exercises  can  be  added  to  and  take  the  place  of  the 
passive  exercises.  Exercises,  either  active  or  passive,  given  for  this 
purpose,  are  best  done  when  the  body  weight  is  removed  from  the 
joint. 

Hot  Air.     Local. — The  local  application  of  dry,  hot  air,  carried 


ARTHRITIS  DEFORMANS  131 

to  a  point  of  from  300°  to  400°  F.,  has  proved  to  be  of  benefit  in  the 
treatment  of  arthritis  deformans  in  many  instances,  especially  in  the 
lighter  cases,  but  the  limb  should  be  placed  in  a  properly  constructed 
oven,  wrapped  in  flannel,  and  the  heat  raised  to  the  highest  comfort- 
able point,  and  the  treatment  should  continue  from  twenty  minutes  to 
an  hour.  In  the  stage  of  acute  inflammation  it  is  not  so  beneficial 
as  at  other  times.  The  heating  of  the  joint  should  be  followed  by 
rest,  and,  in  cases  that  are  not  acute,  massage  following  the  heating 
may  be  of  use. 

Hot  Air.  General. — Hot-air  baths  for  the  whole  body  may  be 
given  by  means  of  a  metal  cylinder  lined  with  asbestos,  which  is  long 
enough  to  include  the  body  up  to  the  armpits  and  is  heated  by  gas, 
gasoline,  or  electricity.  The  patient  lies  in  the  cylinder  and  the  tem- 
perature is  raised  to  350°  or  400°. 

Electric  Light  Baths. — The  use  of  combined  heat  and  light,  given 
off  by  a  number  of  incandescent  electric  light  bulbs  placed  inside  of 
a  box  similar  to  the  ordinary  cabinet  bath,  has  been  found  of  use, 
both  as  a  general  and  local  application.  It  is  said  that  free  perspiration 
is  induced  at  a  lower  temperature  than  when  the  heat  alone  is  used 
without  the  light. 

Massage. — Manual  massage  is  of  assistance  in  stimulating  the 
local  circulation  and  promoting  the  absorption  of  some  of  the  swelling. 
It  is  a  remedy  often  of  use,  but  sometimes  exaggerates  the  symptoms. 
It  should  be  used  with  judgment  and  the  joint,  if  acutely  irritated, 
should  be  very  lightly  rubbed,  the  attention  being  directed  to  the  tis- 
sues about  the  joint.  As  the  tolerance  of  the  joint  increases  it  may 
receive  more  massage,  but  many  cases  are  rendered  more  acute  and 
painful  by  the  use  of  massage  applied  too  roughly,  or  for  too  long  a 
time.  Mechanical  vibratory  stimulation  is  of  use  in  connection  with, 
or  replacing  massage.  It  may  be  given  as  a  general  treatment  for 
purposes  of  stimulation,  and  locally  it  serves  as  a  sedative  to  muscular 
irritability. 

Electricity. — Electricity  may  be  of  use  in  the  form  of  galvanism 
applied  once  or  twice  weekly,  or  of  static  electrical  application  made 
more  often.  The  wave  current  and  some  of  the  high-frequency  cur- 
rents applied  either  locally  or  generally  may  be  of  use  with  these  or 
may  replace  them. 

Hydrotherapy. — The  use  of  hydrotherapy  in  this  disease  is  at 
times  of  undoubted  benefit.  The  combination  of  a  change  in  sur- 
roundings, careful  diet,  and  massage,  in  connection  with  the  water 
treatment,  frequently  unite  in  improving  the  patient's  general  and 


1 32  ORTHOPEDIC  SURGERY 

local  condition.  The  use  of  warm  alkaline  baths  may  be  varied  by 
the  use  of  baths  of  hot  mud,  a  mode  of  treatment  for  which  special 
arrangements  are  necessary. 

1  \icnniii  Treatment. — Placing  the  joint  within  a  glass  case  and  ex- 
hausting the  air  by  means  of  a  pump  has  been  tried  with  benefit  in 
some  cases.  It  is  a  means  of  causing  passive  hypenemia. 

Treatment  b\  Passive  Congestion. — A  local  passive  congestion 
can  be  accomplished  in  the  case  of  the  knee,  e.g.,  by  applying  a  bandage 
from  the  foot  up  to  the  knee,  leaving  the  knee  uncovered  and  applying 
an  elastic  bandage  directly  above  the  knee,  sufficiently  tight  to  cause 
a  congestion  of  the  joint.  This  congestion  should  not  be  so  great  as 
to  give  rise  to  a  cold  condition  of  the  surface.  The  tissues  should 
become  blue  and  the  patient  may  suffer  some  discomfort,  but  pain 
should  not  be  experienced.  This  congestion  should  be  allowed  to 
continue  for  from  seven  minutes  to  half  an  hour,  and  massage  should 
be  applied  to  the  joints  afterward. 

OPERATIVE  TREATMENT. — \\Tien  deformities  exist  in  the  lower 
extremity  one  of  two  things  is  necessary.  Either  the  limb  must  be 
straightened  by  apparatus  or  by  operative  means,  unless  gymnastic 
exercises  and  stretching  can  be  used  for  the  purpose. 

Meehanieal  Correction  of  Deformities. — The  same  methods  that 
are  used  in  the  correction  of  deformities  of  tuberculous  disease  can 
also  be  applied  to  the  deformities  following  arthritis  deformans,  with 
the  exception  that  the  latter  occur  more  commonly  in  adults  than  in 
children  and  greater  difficulty  is  met  in  correcting  these  deformities 
without  an  anaesthetic.  On  the  other  hand,  greater  force  can  be  used 
without  clanger  of  suppuration  in  arthritis  deformans  than  is  possible 
in  the  tuberculous  affections. 

Removal  of  Obstructions. — The  operation  consists  of  forcible  cor- 
rection with  or  without  tenotomy,  after  the  removal  of  any  obstruc- 
tive fringes  or  lipomata  if  such  interfere  with  the  motion  of  the  joint, 
or  the  removal  of  exostoses  if  these  act  as  obstructions.  It  is  manifest 
that  when  many  joints  are  involved,  operative  interference  is  to  be 
limited  to  the  most  important  joints  or  the  joints  most  important  for 
locomotion. 

The  surgical  treatment  must  necessarily  be  modified  by  the  locality 
affected  and  whether  the  process  is  a  proliferation  or  degeneration  or 
arthritis  deformans  in  children  ("Still's  Disease"). 

The  arthritis  deformans  in  children  is  of  the  proliferative  type 
and  demands  the  most  careful  treatment,  as  much  can  be  done  to  check 
the  progress  of  the  affection  and  to  limit  the  resulting  disability. 


ARTHRITIS  DEFORMANS  133 

The  development  of  deformities  must  be  prevented  by  apparatus 
or  traction,  the  use  of  the  limb  promoted,  and  existing  deformities 
corrected.  The  mechanical  appliances  used  for  the  deformities  of 
tuberculous  and  paralytic  deformities  will  be  often  of  service. 

ARTHRITIS  DEFORMANS  IN  THE  LARGER  JOINTS  AND  SPINE. 

Some  modification  of  treatment  is  needed  where  the  larger  joints 
and  spine  are  attacked,  as  activity  depends  largely  upon  the  freedom 
from  disability  of  these  parts. 

SPINE. 
SPONDYLITIS  DEFORMANS. 

Osteoarthritis  of  the  spine,  ankylosing  inflammation  of  the  spine, 
rigidity  of  the  spine,  spondylose  rhizomelique,  Bechterew's  disease  of 
the  spine,  Steifigkeit  der  Wirbelsaule,  etc.,  are  names  which  have  been 
applied  to  the  condition.  The  essential  character  of  this  affection  is 
a  chronic  and  progressive  stiffening  of  the  spine,  accompanied  by 
pain. 

The  spinal  column  is  attacked  by  both  the  proliferative  and  the 
degenerative  type  of  arthritis  deformans. 

Pathology  and  Etiology. — When  the  process  involves  the  spine  the 
same  differences  in  types  may  be  seen  as  those  described.  The  affec- 
tion may  be  characterized  by  stiffness  without  much  bony  change,  or 
the  bony  change  may  be  marked  and  the  deformity  distressingly 
noticeable. 

In  the  proliferative  type,  the  ankylosis  usually  also  involves  the 
costo-vertebral  articulation.  The  process  often  involves  the  whole 
spinal  column,  but  it  may  be  limited  to  a  portion  of  the  spine.  The 
affection  may  be  associated  with  arthritis  in  the  other  joints,  or  the 
process  may  be  limited  to  the  spinal  column  and  ribs.  There  is  little 
deformity,  but  marked  stiffness,  and  the  spinal  column  may  lose  its 
physiological  curves. 

In  the  degenerative  type  the  affection  attacks  regions  of  the  spinal 
column.  The  degenerative  changes  already  described  take  place,  and 
osseous  deposits  and  marginal  hypertrophies  develop,  and  the  column 
becomes  stiff  and  bowed. 

The  patient  walks  more  or  less  bent  over  by  the  dorsal  kyphosis, 
and  in  stooping  the  motion  is  entirely  from  the  hips.  In  lying  down 


ORTHOPEDIC  SURGERY 


the  curves  are  not  affected  or  obliterated  in  the  later  stages.  The 
lower  spine  is  generally  first  affected  and  the  cervical  last.  In  the 
severest  cases  the  spine  is  stiff  from  the  sacrum  to  the  occiput,  and 
permits  no  more  motion  than  would  an  iron  rod,  and  in  the  severer 
cases  the  ribs  are  ankylosed  at  their  junction  with  the  spine,  and  the 


FIG.  119. — Vertical  Sec- 
tion through  Part  of 
the  Rodies  of  Sacral 
Vertebra;  from  a  Case 
of  Spondylitis  Defor- 
mans.  Drawing  shows 
the  new  formation  of 
dense  bone  along  the 
anterior  surface  which 
is  especially  marked 
at  the  intervetebral 
discs.  (By  the  courtesy 
of  the  Department  of 
Surgical  Pathology  of 
the  Harvard  Medical 
School.) 


FIG.  1 20. — Spondylitis  Deformans,  Showing 
Deposits  of  Bone  at  the  Sides  of  the  Verte- 
brae. (Warren  Museum.) 


chest  wall  scarcely  moves  in  inspiration.  In  less  severe  cases  the  spine 
is  not  involved  to  the  whole  extent,  but  marked  stiffness  without 
angular  projection  exists  in  a  portion  of  the  column.  Stiffening  and 
flexion  of  the  hips  is  present  in  some  of  the  cases,  and  leads  to  a 


ARTHRITIS  DEFORMANS 


135 


most  distressing  gait,  in  which  the  whole  body  is  carried  bent  for- 
ward.    Pain  in  the  thighs  is  a  common  symptom. 

The  course  of  the  disease  is  chronic  in  the  extreme,  and  its  dura- 
tion covers  many  years.  The  bone  inflammation  has  no  destructive 
tendency  and  accomplishes  nothing  more  than  stiffening  the  vertebral 
column.  The  impairment  of  the  general  health  consequent  upon  this 
is  generally  not  so  severe  as  one  would  anticipate. 

The  diagnosis  of  the  proliferative  type  of  the  affection  can  be 
made  by  recognizing  the  rigidity  of  the  entire  vertebral  column  with- 
out the  angular  prominence  of 
Pott's  disease.  The  immobility 
of  the  ribs  is  a  pathognomonic 
sign  of  the  affection,  and  the 
involvement  of  other  joints 
would  merely  confirm  one's 
opinion  of  the  character  of  the 
disease.  A  diagnosis  of  the  de- 
generative type  is  made  by  the 
deformity  and  increasing  stiff- 
ness. 

Prognosis.— It  need  hardly 
be  said  that  the  prognosis  is 
unfavorable  as  to  complete  re- 
covery. Early  cases  should 
pass  into  a  quiescent  stage  by 
means  of  proper  treatment 
and  the  pain  should  subside. 
Most  cases  are  improved  or  re- 
lieved by  support  and  fixation. 
Treatment. — The  general 
measures  likely  to  be  of  use 
have  been  described.  In  the 
acute  stage  the  use  of  fixation 
is  indicated.  A  plaster  or 
leather  jacket,  applied  without 
suspension,  or  some  form  of 
supporting  corset  are  the  best 
means  of  obtaining  this.  As 
the  acute  symptoms  quiet 
down,  massage  is  of  value. 
The  spine  should  be  protected  by  a  support  so  long  as  it  is  painful 


FIG.  121. — Arthritis  Deformans  Following  Gonor- 
rhoea Involving  Spine  and  Many  Other  Joints. 
Spine  perfectly  rigid  except  upper  cervical  re- 
gion. (By  the  courtesy  of  the  Department  of 
Surgical  Pathology  of  the  Harvard  Medical 
School.) 


136 


ORTHOPEDIC  SL'RGERY 


and  irritable.     The  use  of  manipulation  to  ward  off  the  approaching 
ankylosis  is  harmful  and  undesirable  at  all  stages  of  the  affection. 

HIP. 

Arthritis  deformans  of  the  hip-joint  is  an  affection  which  is  not 
uncommon  in  patients  above  the  age  of  forty-five.     It  may  occur  as 


FIG.    i->2. — Arthritis    Deformans   of    Hip.       (Warren  Museum.) 

a  monarticular  affection  or  in  connection  with  a  simultaneous  affection 
of  some  of  the  other  joints. 

Pathology  and  Etiology. — When  affecting  the  hip  the  disease  has 
been  known  as  senile  coxitis,  malum  coxie  senile,  etc.  It  begins  in 
many  cases  insidiously,  while  in  others,  and  especially  monarticular 


ARTHRITIS  DEFORMANS 


137 
The  affection  may 


cases,  it  follows  after  a  fail  upon  the  trochanter. 
occur  in  adolescents  and  children. 

Symptoms. — The  affection  begins  with  pain  in  and  about  the  joint, 
often  shooting  down  the  course  of  the  sciatic  nerve  at  the  back  of 
the  leg  instead  of  down  the  front,  as  in  epiphyseal  ostitis.  Move- 
ments of  the  joint  beyond  a  certain  arc  are  painful,  and  a  noticeable 
limp  is  present.  Muscular  atrophy  of  the  limb  comes  on  and  the  nates 
of  the  affected  side  are  flaccid  and  flattened,  and  apparent  shortening 


FIG.    123. — Arthritis   Deformans   of   Hip-joint,  Showing   Shortening   of  Xeck   of   Femur.      Broad- 
ening of  head  and  broadening  and  loss  of  depth  in  acetabulum.      (Warren  Museum.) 

from  flexion  and  adduction  may  be  present  in  the  diseased  limb,  as 
well  as  true  bone  shortening.  Muscular  fixation  is  at  first  not  a  promi- 
nent symptom,  except  in  very  sensitive  conditions  of  the  joint,  but 
the  arc  of  motion  gradually  diminishes,  until  finally  the  joint  may 
become  entirely  stiff  in  perhaps  a  normal  position,  or  perhaps  adducted 
or  flexed. 

Diagnosis. — The  affection  is  likely  to  be  confused  with  other 
forms  of  inflammation  of  the  hip-joint. 

Treatment. — Arthritis  deformans  of  the  hip  demands  treatment, 
first  to  relieve  the  pain,  and  secondly  to  correct  the  deformity.  The 
symptom  of  pain  is  rarely  so  great  as  to  cause  disability.  In 


138  ORTHOPEDIC  SURGERY 

such  cases  hot  baths,  massage,  galvanism,  hot  packs,  and  the  other 
measures  mentioned  are  often  of  use.  The  use  of  crutches  and  canes 
will  often  be  needed.  The  deformities  which  follow  this  affection  are 
usually  those  seen  in  hip  disease,  but  they  are  more  gradual  in  develop- 
ment. Joint  irritation  from  overuse  is  to  be  met  here  as  elsewhere 
by  rest  to  the  joint.  The  use  of  the  protection  splint  described  in  hip 
disease  may  temporarily  be  necessary  when  the  joint  is  acutely  irri- 
tated. 

More  is  to  be  gained  ordinarily  by  gradual  correction  by  mechani- 
cal means  than  by  forcible  straightening  in  this  class  of  affections  of 

the  hip. 

KNEE. 

The  knee  is  one  of  the  large  joints  most  frequently  attacked  by 
this  affection. 

Symptoms. — Pain,  irritability,  and  a  sense  of  stiffness,  especially 
after  sitting  a  while,  are  the  most  frequent  early  symptoms.  After 
walking  a  while  the  knees  feel  freer,  but  they  stiffen  up  after  rest 
and  are  also  painful  in  the  morning  on  waking.  Going  up-  and  down- 
stairs is  difficult  and  irritating.  The  discomfort  is  increased  by  cold 
and  wet  and  by  overuse,  and  acute  attacks  of  pain  and  swelling  may 
occur. 

In  some  cases  the  affection  progresses  insidiously  and  gradually, 
without  acute  attacks.  On  examination  in  the  early  cases  the  synovial 
membrane  is  somewhat  thickened  and  the  surface  depressions  of  the 
knee  are  filled  out,  and  the  movements  are  almost  always  attended 
by  a  more  or  less  marked  grating. 

In  the  progressive  cases  and  in  those  of  longer  standing  the  pain- 
ful symptoms  are  more  marked,  and  heat  and  tenderness  are  promi- 
nent, according  to  the  acuteness  of  the  symptoms. 

At  times  there  is  on  walking  a  sensation  of  catching  in  the  knee, 
as  if  something  had  been  squeezed  between  the  bones.  This  points 
to  an  hypertrophied  condition  of  the  synovial  fringes.  The  first  limi- 
tation of  motion  is  a  resistance  to  complete  extension,  and  the  tendency 
to  a  flexed  position  is  marked,  favoring  ankylosis  in  this  position. 

In  general,  the  tendency  of  the  affection  is  toward  greater  and 
greater  impairment  of  the  joint  motion,  with  wasting  of  the  muscles 
and  atrophy  of  the  skin,  so  that  in  the  advanced  stages  one  can  see 
a  stretched  and  shining  skin  tightly  drawn  over  the  deformed  and 
distorted  joint. 

The  prognosis  depends  largely  upon  the  degree  of  change  in  the 
joint  surface  when  treatment  is  begun.  If  it  is  slight,  as  shown  by 


ARTHRITIS  DEFORMANS 


139 


moderate  thickening  and  soft  grating  on  motion,  much  is  to  be  expected 
from  the  prevention  of  overuse  and  the  regulation  of  the  circulation 
in  the  knee.  If  the  changes  in  the  joint  are  advanced,  and  especially 


FIG.  124. — Arthritis  Deformans,  Bony  Enlargement  of  Knees  with  Effusion.  Palpable  fringes. 
Limitation  of  motion.  Crepitus  and  pain  on  motion.  (By  the  courtesy  of  the  Department 
of  Surgical  Pathology  of  the  Harvard  Medical  School.) 

if  other  joints  are  showing  signs  of  a  progressive  involvement,  the 
outlook  is  less  favorable. 

Treatment. — When  pain  is  present  rest  is  very  strongly  indicated. 
During  the  quiescent  stage,  the  local  measures  described  above  should 
be  used. 

\Yhen  ankylosis  of  the  knee  in  a  faulty  position  has  resulted  from 
arthritis  deformans,  brisement  force  is  to  be  tried  for  its  rectification. 
It  is  not,  of  course,  to  be  expected  that  motion  will  be  present  in  the 
joint  in  its  new  position,  yet  some  motion  may  be  preserved  in  the 
joint. 


CHAPTER  VIII. 

OTHER  AFFECTIONS  OF  THE  BONES  AND  JOINTS. 

SPRAINS. 

THE  name  sprain  is  used  to  designate  a  common  condition  caused 
by  wrenches  and  twists,  and  occasionally  by  blows  to  the  joints.  The 
injury  may  be  most  marked:  (i)  in  the  ligaments;  (2)  in  the  synovial 
membrane,  which  may  become  the  seat  of  an  acute  synovitis;  (3)  in 
the  tendons  surrounding  the  joint.  Any  one  of  these  or  any  combina- 
tion of  them  may  exist  in  a  given  case. 

The  symptoms  consist  of  pain,  more  or  less  severe,  and  tenderness, 
localized  at  the  point  of  the  chief  injury;  in  the  more  superficial  joints 
ecchymosis  of  the  subcutaneous  tissue  appears,  followed  by  swelling. 
A  period  of  greater  or  less  disability  follows,  during  which  the  symp- 
toms diminish  in  severity,  and  in  favorable  cases  entirely  disappear. 

The  diagnosis  from  fractures  is  important  and  is  to  be  made  with 
great  care.  In  this  the  .r-ray  is  of  much  use. 

The  prognosis  is  favorable  and  progress  is  hastened  by  treatment. 

\Yhen  the  injury  to  the  tissues  is  severe  and  tissues  are  torn,  a 
period  of  fixation  of  the  joint  and  compression  are  advisable  by  means 
of  a  plaster-of-Paris  bandage  or  a  light  splint. 

Such  fixation  should  be  temporary,  and  measures  to  stimulate  the 
circulation  undertaken  as  soon  as  possible — massage,  electricity,  dry 
heat,  douches,  and  graduated  use. 

In  less  severe  cases  adhesive  plaster  strapping  affords  relief,  espe- 
cially at  the  ankle.  In  many  cases,  where  the  ligaments  are  not  torn, 
dry  heat  and  massage  should  be  begun  at  once  and  hypenemia  used. 

Sprain  Fractures. — In  many  injuries  classed  as  sprains,  an  .r-ray 
will  show  the  existence  of  complete  or  incomplete  fractures  of  the 
articular  ends  of  the  bones,  often  involving  the  articular  surface.  The 
treatment  of  such  injuries  is  that  of  fractures. 

Epiphyseal  Strains. — In  the  case  of  children  or  adolescents  whose 
epiphyses  have  not  yet  united,  injuries  and  strains  to  the  joints  may 
be  complicated  by  a  strain  or  partial  displacement  of  the  epiphysis  on 
the  shaft,  resulting  in  congestion  of  the  epiphysis  manifested  by  pain 

140 


OTHER  AFFECTIONS  OF  THE  BONES  AND  JOINTS    141 

and  tenderness  often  prolonged.  The  x-ray  may  fail  to  show  any  gross 
displacement,  but  the  long  continuance  of  the  joint  symptoms  in  such 
cases  should  excite  suspicion,  and  treatment  should  be  prolonged  until 
such  symptoms  have  disappeared. 

SPINE. 

Sprains  of  the  Spine. — -After  a  severe  wrench  or  twist  of  the  spine 
or  after  some  accident  causing  extreme  motion  in  one  or  another  direc- 
tion, a  condition  of  pain  and  disability  ensues,  presenting  much  the 
same  symptoms  as  those  accompanying  sprains  in  the  other  joints. 

Stiffness,  pain  on  motion,  and  perhaps  lateral  deviation  of  the 
spine  occur  in  the  severer  cases.  In  the  milder  cases  the  patient 
should  avoid  actual  exercise  and  movements  which  are  painful.  In 
the  severer  ones,  the  back  may  be  supported  by  adhesive  plaster  strap- 
ping, plaster-of-Paris  jackets,  or  corsets,  while  in  the  severest  class 
recumbency  is  necessary. 

HIP. 

Sprains  of  the  hip  are  manifested  clinically  as  synovitis  of  that 
joint  and  are  described  in  that  connection. 

KNEE. 

On  account  of  the  strength  of  the  muscles  and  ligaments  con- 
trolling the  joint,  gross  ligamentous  or  muscular  injury  are  rare  at 
this  joint,  the  results  of  trauma  being  generally  expressed  as  synovitis. 

Lesions  of  the  tubercle  of  the  tibia  are  seen  l  in  which,  after  a 
sudden  strain  falling  upon  the  partially  extended  knee,  or  after  no 
assignable  strain,  swelling  and  tenderness  of  the  tubercle  of  the  tibia 
have  followed,  associated  with  pain  on  complete  extension  of  the  leg. 
The  condition  is  seen  chiefly  in  boys  at  or  about  the  age  of  puberty. 

The  condition  would  seem  to  be  due  in  some  cases  to  an  inflamma- 
tion of  the  bursa  under  the  patella  tendon,2  and  in  others  to  an  injury 
of  the  partly  ossified  and  vascular  epiphysis  of  the  tubercle  of  the 
tibia.  X-ray  appearances  are  apt  to  be  misleading,  as  during  the 
normal  ossification  at  this  age  the  tubercle  appears  to  be  torn  loose 
from  the  tibia  below.  Only  when  there  is  a  marked  difference  in  the 
radiographs  of  the  two  knees  and  the  tibial  tubercle  is  displaced 

1  R.  B.  Osgood  :  Boston  Med   and  Snrg.  Journal,  January  29,  1903. 

2  Lovett :  Report  Boston  City  Hospital,  series  viii.,  1897,  p.  345. 


i42  ORTHOPEDIC  SURGERY 

upward  is  one  justified  in  diagnosticating  any  displacement  of  it  by 
force.  The  treatment  consists  of  fixation  when  necessary,  but  in  the 
milder  cases  restricted  use  is  sufficient. 


ANKLE. 

On  account  of  its  flexibility  and  its  constant  liability  to  twists,  the 
ankle  is  the  commonest  location  of  sprains.  The  location  of  the 
tenderness,  swelling,  and  pain  on  manipulation  will  serve  to  identify 
the  anatomical  location  of  the  injury. 

The  treatment  consists  either  in  fixation  in  a  stiff  bandage  or,  what 
is  in  most  cases  advisable,  in  immediate  massage  or  hot-air  baths,  or 
both. 

Chronic  Sprain. — In  many  cases  the  treatment  is  too  soon  discon- 
tinued after  sprains,  and  a  tenosynovitis  or  subacute  inflammation 
of  part  of  the  synovial  sac  may  persist  and  be  accompanied  by  local 
heat  and  tenderness.  In  other  cases  fixation  has  been  continued  too 
long,  and  wasting  of  the  muscles  and  disturbance  of  the  local  circula- 
tion and  innervation  have  induced  a  condition  of  irritability.  The 
treatment  consists  of  measures  to  stimulate  the  local  circulation  and 
the  careful  and  graduated  resumption  of  use  with  the  treatment  of 
any  static  error  in  the  foot. 

The  sprains  of  other  joints  do  not  require  especial  mention. 

CHRONIC    SYNOVITIS. 

Chronic  serous  synovitis  is  also  known  by  the  names  of  dropsy  of 
the  joint,  hydrarthros,  hydrarthrosis,  etc. 

Apart  from  the  cases  in  which  chronic  serous  synovitis  is  ( I ) 
merely  the  continuance  of  the  acute  condition,  its  cause  is  to  be  sought 
(2)  in  the  presence  of  some  mechanical  irritation  (such  as  hypertro- 
phied  synovial  fringes,  loose  bodies,  etc.),  (3)  in  the  presence  of  some 
infectious  process  (such  as  gonorrhoea  or  syphilis),  or  (4)  in  connec- 
tion with  some  general  disturbance  (such  as  arthritis  deformans, 
haemophilia,  etc.).  Intermittent  synovitis  should  be  mentioned  as  not 
coming  under  any  one  of  these  heads. 

The  pathological  changes  in  simple  chronic  synovitis  are  repre- 
sented by  increase  of  vascularity  and  thickening  of  the  synovial  mem- 
brane, with  hypertrophy  of  the  synovial  villi.  The  subsynovial  tissue 
thickens  in  cases  of  long  standing  along  with  the  capsule,  and  the 
ligaments  may  become  weakened  and  stretched. 

Intermittent  synovitis,  also  called  intermittent  hydrops,  is  a  well- 


OTHER  AFFECTIONS  OF  THE  BONES  AND  JOINTS    143 

recognized  but  rather  infrequent  affection,  accompanied  by  no  definite 
pathological  changes,  except  perhaps  a  little  laxity  or  thickening  of 
the  joint  capsule.  The  knees  are  most  often  affected.  No  etiology 
has  been  formulated  for  the  condition,  the  sexes  being  equally  affected 
and  the  cases  pretty  evenly  distributed  through  adult  life.  The  char- 
acteristic of  the  affection  is  a  non-inflammatory  serous  effusion  occur- 
ring at  more  or  less  regular  intervals,  lasting  a  few  days  and  disap- 
pearing spontaneously,  to  return  again  and  again. 
No  satisfactory  treatment  has  been  formulated. 

HIP. 

Synovitis  of  the  hip  may  occur  in  children  or  adults.  It  may  follow 
any  of  the  causes  producing  synovitis,  but  the  common  clinical  ante- 
cedents are  either  trauma,  rheumatism,  or  gonorrhoea.  Its  importance 
clinically  is  its  resemblance  in  children  to  tuberculous  hip  disease. 

After  a  fall  or  during  a  "  rheumatic  "  attack,  pain,  lameness,  mus- 
cular spasm,  flexion  deformity,  night  cries,  and  muscular  atrophy  may 
be  present  for  a  while.  These  symptoms  may  disappear  so  rapidly 
that  one  is  led  to  infer  that  synovitis  has  been  present  rather  than 
tuberculosis  or  acute  osteomyelitis. 

In  children  the  diagnosis  of  synovitis  of  the  hip-joint  should  be 
made  only  when  recovery  has  occurred  in  a  few  weeks  and  has  proved 
permanent. 

Treatment. — In  children  cases  of  synovitis  of  the  hip-joint  are  to 
be  treated  in  the  same  way  as  cases  of  tuberculous  ostitis. 

Cases  in  adults,  which  are  clearly  to  be  recognized  as  synovitis, 
should  be  treated  by  rest  to  the  joint,  including,  if  necessary,  either 
traction  or  protection  by  apparatus,  followed  by  massage  and  stimula- 
tion of  the  local  circulation. 

KNEE. 

Chronic  Synovitis. — Chronic  serous  synovitis  is  at  times  the 
sequel  of  an  acute  or  subacute  attack.  In  such  a  case  the  acute  symp- 
toms gradually  subside,  leaving  a  joint  somewhat  thickened  and  con- 
taining fluid.  If  the  condition  persists,  the  muscles  become  weakened 
and  relaxed,  and  lateral  mobility  may  be  present.  The  weakness  of 
the  muscles  is  itself  a  source  of  a  vulnerable  joint.  At  other  times 
the  chronic  synovitis  is  the  result  of  an  irritation  caused  by  loose 
bodies  in  the  joint,  displaced  semilunar  cartilages,  hypertrophied 


144  ORTHOPEDIC  SURGERY 

synovial  fringes,  or  lipoma  arborescens.  The  continued  strain  on 
the  knees  induced  by  flat-foot  is  at  times  a  cause  of  chronic  synovitis. 
At  other  times  it  exists  in  connection  with  constitutional  disease,  such 
as  syphilis  and  gonorrhoea,  and  the  intermittent  form  must  be  men- 
tioned. 

The  treatment  of  the  chronic  form  which  has  lasted  over  from 
the  acute  stage  consists  in  fixation,  if  heat,  pain,  and  tenderness  are 
present,  along  with  compression  by  bandaging  or  strapping  over  the 
front  of  the  joint  with  adhesive  plaster.  This  fixation  should  be  fol- 
lowed by  massage,  hot-air  baths,  and  douches  to  restore  the  circulation 
and  to  improve  the  muscular  condition  along  with  the  gradual  re- 
sumption of  use. 

If  the  synovitis  exists  as  the  result  of  mechanical  irritation,  the 
irritating  cause  should  be  removed  by  operation.  If  flat-foot  is  pres- 
ent it  should  be  corrected. 

As  a  symptom  of  constitutional  disease,  treatment  of  the  systemic 
condition  is  indicated.  In  resistant  cases  in  which  the  diagnosis  is  net 
clear,  the  joint  should  be  opened,  explored,  and  any  irritating  cause 
removed. 

Hypertrophy  of  the  Synovial  Villi. — As  the  result  of  a  synovitis, 
or  in  connection  with  continued  strain  of  the  knees  as  in  flat-foot,  or 
in  arthritis  deformans,  hypertrophy  of  the  synovial  fringes  occurs  to 
an  extent  that  makes  of  them  foreign  bodies.  The  symptoms  caused 
by  them  are  pain,  effusion  varying  at  times,  creaking,  occasional 
catching,  and  some  swelling  of  the  joint  membrane,  with  perhaps 
tenderness. 

The  treatment  at  first  should  consist  of  fixation  in  the  severer 
cases,  and  compression  by  plaster  strapping  over  the  front  of  the 
joint  in  the  milder  cases.  Douches,  massage,  and  the  measures  suited 
to  the  treatment  of  chronic  synovitis  should  follow.  Flat-foot  should 
be  corrected  and  the  knee  in  general  placed  under  the  most  favorable 
mechanical  conditions  possible.  If  this  does  not  control  the  affec- 
tion, the  joint  should  be  opened  by  an  anterior  incision  on  one  or  both 
sides  of  the  patella,  the  interior  of  the  joint  inspected  and  explored, 
and  the  projecting  fringes  removed  with  sharp  scissors  or  a  knife. 
The  joint  should  be  fixed  for  two  or  three  weeks,  after  which  passive 
motion  and  graduated  use  are  begun. 

Loose  bodies  in  the  joints  are  found  most  often  in  the  knee,  but 
occasionally  in  other  articulations.  They  can  be  divided  into  classes, 
according  to  their  structure,  as  follows :  fibromatous,  lipomatous,  chon- 
dromatous. 


OTHER  AFFECTIONS  OF  THE  BONES  AND  JOINTS    145 

Loose  bodies  lie  free  in  the  joint  or  are  attached  by  a  slender 
pedicle.  They  may  vary  in  size  from  that  of  a  small  pea  to  that 
of  a  horse  chestnut,  and  are  of  all  shapes.  Sometimes  they  are 
facetted  and  crowded  together  like  the  carpal  bones,  and  again  they  are 
mulberry-shaped  or  pyriform.  In  one  joint  they  may  appear  singly 
or  in  great  numbers. 

They  are  often  found  in  connection  with  the  changes  known  as 
arthritis  deformans,  and  also  in  joint  disease  of  various  types.  They 
may  be  found  in  connection  with  joint  tuberculosis.  In  certain  cases 
no  cause  can  be  assigned  for  their  occurrence. 

In  a  majority  of  cases  the  first  intimation  to  the  patient  that 
anything  is  wrong  is  that  \vhile  in  the  act  of  walking  or  stooping  he 
is  seized  with  such  agonizing  pain  in  the  knee  that  he  may  fall  to 
the  ground,  in  many  cases  overcome  with  the  sensation  of  faintness 
and  sickening  pain,  and  such  an  occurrence  is  apt  to  be  followed  by 
an  attack  of  synovitis  lasting  several  days.  These  attacks  are  likely 
to  be  repeated  without  any  assignable  cause.  On  manipulation  of  the 
joint  with  the  fingers  it  is  often  possible  to  detect  a  loose  body,  which 
shifts  its  position  and  is  found  first  in  one  part  of  the  joint  and 
then  in  another.  The  most  common  spot  where  they  can  be  detected 
externally  is  in  the  pouch  over  the  external  or  internal  condyle  of 
the  femur,  and  when  one  of  these  substances  has  been  found  it  is 
desirable  to  see  if  others  are  present  in  the  joint. 

With  repetition  of  attacks  the  joint  becomes  more  tolerant  and 
the  synovitis  less  severe. 

Finding  a  movable  body  which  can  be  slipped  from  place  to  place 
by  manipulation  establishes  the  diagnosis.  In  cases  in  which  the 
loose  body  cannot  be  found,  one  must  depend  largely  upon  the  history, 
making,  however,  frequent  examinations  under  different  conditions 
with  the  hope  of  ultimately  detecting  the  foreign  body.  The  .r-ray 
may  be  of  use. 

The  diagnosis  between  loose  bodies,  hypertrophied  synovial 
fringes,  and  dislocation  of  the  semilunar  cartilage  is  often  a  difficult 
one  to  make,  and  dependence  must  be  placed  chiefly  upon  tenderness 
in  a  very  small  spot  over  the  head  of  the  tibia  as  establishing  the 
probable  occurrence  of  dislocation  of  one  of  the  semilunar  cartilages. 
Diagnosis  has  sometimes  to  be  made  by  exploratory  incision. 

Treatment. — In  cases  in  which  the  loose  body  gives  but  little 
inconvenience  and  is  kept  from  passing  between  the  ends  of  the  bone 
by  a  knee-cap,  it  may  not  be  advisable  to  undertake  operative  treat- 
ment. In  other  cases,  especially  in  arthritis  deformans,  the  joint 


146  ORTHOPEDIC  SURGERY 

may  have  become  so  much  impaired  by  the  disease  that  even  if  a 
foreign  body  were  removed  little  would  be  gained.  In  the  great 
majority  of  cases,  however,  inasmuch  as  the  disease  occurs  in  other- 
wise healthy  persons,  mostly  young  adults,  the  operative  removal  of 
the  foreign  body  is  advisable. 

Lipoma. — Fatty  growths  may  form  in  the  joints,  acting  as  foreign 
bodies  and  causing  chronic  or  recurrent  attacks  of  acute  synovitis. 


FIG.     125. — Tibial    Joint    Surfaces    of    Knee    Seen    from    Above,    Showing    Semilunar    Cartilages. 

(Pick.) 


Although  other  joints  are  not  exempt,  the  common  seat  of  occurrence 
is  in  the  knee. 

The  lipomata  vary  in  size,  being  sometimes  as  large  as  an  egg,  and 
attached  to  the  synovial  membrane  by  a  pedicle.  In  shape  they 
may  be  regular  or  irregular  and  are  studded  with  small  tabs  of  fatlike 
tissue.  Once  formed,  such  a  mass  acts  as  a  foreign  body,  and  clinically 
a  swollen  joint  is  found  with  little  or  no  effusion.  The  function  is 
imperfect  and  pain  may  be  present,  and  the  joint  is  liable  to  lock  in 
partial  extension.  The  swelling  is  chiefly  noted  at  the  side  of  the 
patella  tendon.  The  treatment  consists  in  the  removal  of  the  mass. 

Dislocation  of  the  Semilunar  Cartilages  (Key's  Internal  De- 
rangement).— The  affection  is  nearly  always  traumatic  in  origin  and 
consists  in  the  tearing  loose  from  its  tibial  attachment  of  the  internal 


OTHER  AFFECTIONS  OF  THE  BONES  AND  JOINTS    147 

or  external  semilunar  cartilage.     The  internal  is  the  one  most  fre- 
quently displaced. 

The  symptoms  are  in  a  measure  similar  to  those  caused  by  loose 
bodies,  and  similar  to,  but  generally  rather  more  than,  those  caused 
by  hypertrophied  synovial  fringes  and  the  like.  The  patient,  by  some 
violent  muscular  effort  or  by  some  sudden  twist,  as  in  dancing,  tennis, 
kicking  football  or  falling  from  a  horse  or  carriage,  wrenches  or 
twists  the  knee  and  finds  it  impossible  to  extend  it  fully,  and  walks 
with  it  bent  in  the  way  described,  suffering  much  pain,  and  a  sharp 


FIG.     126. — Three    Right    Internal     Semilunar    Cartilages,   Showing    Fracture    Opposite    Internal 
Lateral  Ligament,  Upper  Surface.      (Tenney.) 

attack  of  synovitis  follows.  On  examination  one  may  find  a  protrusion 
of  one  of  the  semilunar  cartilages,  which  establishes  the  diagnosis. 

In  some  instances  much  tenderness  can  be  found  over  the  internal 
cartilage  at  the  front  of  the  joint  where  none  is  present  over  the 
outer. 

The  affection  is  masked  in  many  patients  by  the  severity  of  the 
acute  synovitis  which  follows  the  injury,  and  the  true  character  of  the 
accident  may  not  be  learned  for  a  long  time  afterward.  One  occur- 
rence of  the  accident  predisposes  to  subsequent  attacks.  Lateral 
mobility  of  the  knee  is  likely  to  exist  in  cases  of  long  standing.  This 
dislocation  affects,  for  the  most  part,  persons  between  twenty  and 
fifty  years  of  age,  and  men  are  much  more  frequently  affected  than 
women ;  it  rarely  occurs  in  children. 

Patients  who  are  liable  to  the  displacement  soon  learn  the  manipu- 
lation of  reduction  themselves.  The  knee  should  be  bent  to  its  fullest 
extent ;  the  tibia  should  then  be  drawn  away  from  the  femur  as  far 
as  possible,  to  separate  the  joint  surfaces,  at  the  same  time  rotating 


ORTHOPEDIC  SURGERY 


the  tibia  inward  or  outward  as  the  internal  or  external  cartilage  is 
displaced,  and  then  the  leg  should  be  extended  quickly  but  not  forcibly 
to  its  fullest  extent,  while  the  surgeon  manipulates  with  the  thumb 
the  situation  of  the  semilunar  car- 
tilages,   especially    if   any   undue 
prominence   should   be    felt.      An 
anaesthetic  may  be  necessary. 

The  cartilage,  after  reduction, 
may  become  united  to  the  tibia  by 
its  former  attachments  or  it  may 
remain  loose,  to  cause  further  at- 
tacks; or,  less  commonly,  entire 
detachment  of  the  torn  piece  may 
occur,  in  which  case  it  becomes  a 
loose  body  of  the  cartilaginous 
class. 

The  treatment  after  the  origi- 
nal accident  is  reduction  of  the 
displaced  cartilage,  followed  by 
the  usual  treatment  for  the  acute 
synovitis  which  ensues.  If  the 
attacks  recur,  especially  on  slight 
cause,  it  is  likely  that  the  cartilage 
has  been  permanently  loosened 
from  its  attachments  and  will  in 
all  probability  become  a  source  of  further  trouble.  The  treatment 
may  under  these  circumstances  be  mechanical  or  operative. 

1.  Mechanical  Treatment. — Although  the  use  of  knee-caps  with 
pads  beside  the  patella,  elastic  bandages,  etc.,  may  prove  of  use  in 
preventing  in  part  future  attacks,  they  are  to  be  regarded  as  palliative 
rather  than  curative. 

The  apparatus  advocated  by  Shaffer  for  this  condition  consists  of 
an  outside  upright  attached  to  the  boot  and  reaching  to  the  upper  part 
of  the  thigh,  and  an  inside  upright  reaching  from  the  upper  thigh 
to  the  upper  part  of  the  calf,  with  a  pad  placed  over  the  inner  aspect 
of  the  knee.  The  apparatus  is  jointed  at  the  knee,  but  the  joint  is 
arranged  to  prevent  full  extension  of  the  knee.  The  object  of  this 
treatment  is,  by  preventing  harmful  motions  and  positions  for  some 
months,  to  produce  a  reunion  of  the  cartilage  to  its  proper  attach- 
ments and  a  return  of  the  ligamentum  patellae  to  its  proper  length. 

2.  Operative  treatment  is.  as  a  rule,  surer,  quicker,  and  more  ac- 


FIG.  127. — Semilunar  Cartilage  of  Right 
Knee,  Showing  Effects  of  Long-Continued 
Friction.  (Tenney.) 


OTHER  AFFECTIONS  OF  THE  BONES  AND  JOINTS    149 

ceptable  to  the  patient.  The  joint  is  opened  inside  or  outside  of  the 
ligamentum  patellae,  according  to  the  cartilage  displaced,  by  a  vertical 
incision.  The  joint  should  be  explored  and  the  loose  part  of  the 
cartilage  removed.  The  joint  capsule  should  be  stitched  and  the 
wound  closed.  Fixation  should  follow  for  two  or  three  weeks,  after 
which  passive  motion  and  massage  should  be  commenced. 

Cysts  of  the  Knee-Joint. — Cystic  swellings  in  connection  with  the 
larger  joints,  especially  the  knee-joint,  occur  at  times.  These  swell- 
ings are  found  from  time  to  time  in  the  neighborhood  of  the  knee- 
joint,  generally  in  the  popliteal  space.  Such  cysts,  as  a  rule,  connect 
with  the  joint.  The  affection  is  found  most  often  in  early  and  middle 
adult  life.  The  diagnosis  from  bursitis  is  often  difficult.  If  such 
cases  are  troublesome,  extirpation  of  the  sac  is  the  only  treatment 
likely  to  be  of  use. 

Trigger  Knee. — The  so-called  trigger  knee,  described  also  as 
genou  a  rcssort  or  schncllendes  Knie,  is  characterized  clinically  by  a 
disturbance  in  extension  of  the  leg,  which  is  normal  until  about  160° 
is  reached,  which  is  then  completed  with  a  snap  and  forcible  jerk, 
during  which  there  is  also  outward  rotation  of  the  tibia.  It  is  not 
connected  with  any  disease  of  the  knee-joint  nor  any  obvious  abnor- 
mality save  looseness  of  the  ligaments.  The  prognosis  in  children  is 
good,  depending  upon  tightening  of  the  ligamentous  structures  with 
or  without  treatment.  Mechanical  treatment  is  apparently  not  neces- 
sary, at  least  in  children. 

Chronic  synovitis  of  the  ankle-joint  has  been  considered  under 
Chronic  Sprains. 

SHOULDER- JOINT. 

Chronic  synovitis  of  the  shoulder  is  an  affection  existing  either 
as  a  sequel  of  an  acute  attack,  the  result  of  some  injury,  or  as  a  slow, 
persistent  process,  beginning  with  slight  symptoms  easily  disregarded. 
The  earliest  symptom  to  attract  notice  is  stiffness,  observed  partic- 
ularly in  forced  movements,  as  in  placing  the  hand  on  the  head,  etc. 
Pain  is  a  variable  symptom.  A  slight  fulness  about  the  joint  may  be 
detected  at  this  time.  As  the  disease  progresses,  motion  becomes 
more  restricted,  swelling  increases,  and  atrophy  of  the  deltoid  and 
scapular  muscles  gradually  occurs. 

Tenosynovitis  may  exist  and  simulate  closely  chronic  synovitis  of 
the  shoulder. 

Bursitis  of  the  shoulder  is  most  conveniently  spoken  of  in  this 
place,  and  replaces  largely  the  old  term  "  periarthritis,"  loosely  used 


1 5o  ORTHOPEDIC  SURGERY 

to  describe  various  painful  conditions  about  the  shoulder.  When  the 
subdeltoid  bursa  is  involved,  there  are  local  tenderness,  pain  in  motion, 
and  limited  abduction.  Stiffness  of  the  joints  in  an  adducted  position 
comes  on  early,  and  the  condition  is  accompanied  by  atrophy  of  the 
shoulder  muscles.  Bursitis  of  the  subcoracoid  bursa  is  accompanied 
by  tenderness  over  the  bursa,  pain  in  motion,  especially  in  abduction 
and  rotation,  and  by  the  same  general  symptoms  described. 

These  affections  may  result  from  injury  or  come  on  without  ap- 
parent cause,  in  some  instances  being  vaguely  classed  as  "  rheumatic." 
The  diagnosis  of  these  conditions  from  synovitis  and  from  muscular 
strain  is  not  always  easily  to  be  made.  The  tendency  of  all  these 
affections  of  the  shoulder  is  toward  a  chronic  course,  in  most  instances. 

Treatment. — In  these  conditions,  the  indication  is  first  for  rest 
and  fixation.  These  are  readily  secured  by  means  of  a  sling  and  a 
bandage  securing  the  arm  to  the  side.  It  is  important  to  mention 
that  the  weight  of  the  arm  dragging  upon  the  joint  structures  may 
be  a  factor  in  keeping  up  the  pain  and  irritation.  Compression  will 
be  needed  if  there  are  swelling  and  effusion.  Traction  may  be  re- 
quired in  the  severest  cases.  Fixation  should  not  be  continued  longer 
than  there  is  subacute  inflammation,  and  can  be  gradually  discon- 
tinued ;  first  discarding  the  bandage  and  retaining  the  sling,  which 
can  be  discontinued  later.  So  long  as  muscular  irritability  exists,  rest 
is  indicated.  In  these  cases  an  increased  arc  of  motion  and  diminished 
sensitiveness  will  usually  follow  a  few  days'  rest  of  the  joint,  and 
permanent  ankylosis  is  rendered  less  likely  by  the  application  of  timely 
immobilization.  But  in  all  cases  fixation  should  be  promptly  followed 
by  measures  to  restore  motion  and  to  stimulate  the  circulation. 

The  question  of  the  use  of  passive  motion  in  the  convalescent 
stage  does  not  differ  essentially  from  the  same  question  in  other 
joints,  except  that  it  comes  up  oftener.  If  the  stiffness  is  due  to 
adhesions,  manipulation  under  an  anaesthetic,  followed  by  massage, 
etc.,  may  be  of  value;  but  in  the  majority  of  light  cases  gradual 
passive  exercises  will  suffice.  Gentle,  graduated,  passive  motion 
carried  to  the  verge  of  being  painful  is  of  great  advantage  in 
many  cases  of  shoulders  stiffened  from  a  slight  degree  of  chronic 
inflammation.  If  the  stiffness  above  alluded  to  is  the  result  of  the 
fixation  due  to  muscular  spasm,  forcible  passive  motion  will  be  of 
no  use,  as  the  reflex  spasm  will  reappear  after  the  effect  of  the 
anaesthetic  has  passed  away,  as  long  as  the  disease  of  the  joint  remains. 

In  bursitis  of  the  subdeltoid  bursa,  if  fixation  of  the  arm  in  the 
ordinary  position  does  not  afford  relief,  a  splint  may  be  applied  to 


UfBF/iFY  OF 
OTHER  AFFECTIONS  OF  THE  BONES  [A-Wt  JOiNTS::  T53G 

fix  the  arm  at  right  angles  to  the  long  axis  of  the  body;  that  is,  with 
the  humerus  horizontal  in  the  standing  position.  Removal  of  the 
bursa  may  be  required  in  the  most  resistant  cases. 

ELBOW-JOINT. 

Chronic  synovitis  may  appear  in  this,  as  in  other  joints,  from  the 
usual  exciting  causes,  and  presents  the  same  characteristics.  What  is 
popularly  spoken  of  as  a  "  tennis  elbozv  "  is  a  chronic  synovitis  and 
irritability,  in  which  injury  to  the  ligaments,  especially  to  the  internal 
lateral  ligament,  is  a  marked  feature.  Its  treatment  does  not  differ 
from  that  of  a  similar  condition  in  other  joints. 

WRIST. 

Chronic  synovitis  may  occur  under  the  same  conditions  existing  in 
other  joints.  Tenosynovitis  is  characterized  by  pain  on  the  motion  of 
certain  ringers,  with,  perhaps,  a  sensation  of  rubbing  or  creaking  in 
the  affected  tendons,  and  tender  points  are  present  in  the  course  of 
these  tendons. 

The  synovitis  of  other  joints  does  not  require  especial  mention. 

BURSITIS. 

Hip. — Inflammation  of  the  bursae  about  the  hip-joint  must  be  rec- 
ognized as  a  condition  likely  to  give  rise  to  symptoms  possibly 
resembling  hip  disease.  This  inflammation  is  most  often  traumatic, 
but  may  be  tuberculous.  Suppuration  and  the  formation  of  fistulse 
may  occur.  According  to  the  location  of  the  inflammation  the  symp- 
toms will  differ.  The  treatment  consists  of  the  temporary  use  of 
crutches  and  incision  in  the  severer  cases. 

Bursitis  of  the  Knee. — The  various  bursae  about  the  knee  may  be- 
come inflamed  and  give 'rise  to  disability,  often  of  an  obscure  nature. 

HOUSEMAID'S  KNEE. — The  most  common  seat  of  this  affection  is 
in  the  prepatellar  bursa  which  lies  over  the  patella  and  part  of  the  liga- 
mentum  patellae.1  This  affection  is  found  chiefly  in  persons  whose 
occupation  leads  them  to  spend  much  time  in  kneeling.  The  affection 
is  characterized  by  slight  swelling,  sensitiveness  on  pressure,  and  dis- 
comfort in  flexing  the  knee,  which  is  localized  at  the  site  of  the  bursa. 
Palpation  shows  a  more  or  less  distinct  swelling,  which  lies  over  the 
patella  and  which  is  rendered  more  tense  by  the  flexion  of  the  joint. 

1  Bize  ;  Journ.  d'Anat.  et  de  Phys.,  Paris,  xxxii.,  1896,  p.  85. 


SURGERY 

In  the  acute  stage  it  is  likely  to  be  mistaken  for  synovitis  of  the  knee- 
joint,  but  the  patella  does  not  float.  The  chronic  enlargement  of  the 
bursa  is  generall)  the  outcome  of  a  series  of  acute  attacks.  Fluctua- 
tion is  clearly  present,  and  the  swelling  is  more  sharply  localized  to 


FIG.    1 28. — Prepatellar   Bursitis. 

the  region  in  front  of  the  patella  than  in  synovitis.  In  the  chronic 
stage  of  the  affection,  heat,  sensitiveness,  and  discomfort  are  ordinarily 
absent. 

Although  the  acute  affection  shows  a  tendency  toward  recovery 
under  rest,  the  chronic  affection  does  not  have  this  tendency  and  is 
likely  to  continue  unabated,  while  suppuration  sometimes  occurs.  The 
inflammation  of  the  bursa  occasionally  is  found  in  connection  with 
gout,  rheumatism,  or  syphilis. 

Treatment. — The  acute  affection  ordinarily  yields  readily  when 
the  limb  is  placed  in  the  extended  position  upon  a  ham  splint  and 


OTHER  AFFECTIONS  OF  THE  BONES  AND  JOINTS    153 

the  constant  irritation  of  walking  is  avoided.  If  suppuration  occurs, 
incision  affords  the  only  hope  of  relief.  In  chronic  bursitis  the  most 
satisfactory  treatment  is  to  lay  the  entire  bursa  open  by  a  crucial 
incision  and  dissect  out  the  tough  fibrous  sac. 

BURSITIS  OF  THE  DEEP  PREPATELLAR  BURSA. — This  bursa  lies  be- 
neath the  ligamentum  patellae  next  to  the  tibia,1  and  the  symptoms 
of  its  inflammation  are  pain  in  complete  extension  of  the  leg,  referred 
to  the  tubercle  of  the  tibia;  pain  and  tenderness,  referred  to  the  patella 
tendon;  apparent  enlargement  of  the  tubercle  of  the  tibia,  and  bulging 
at  the  sides  of  the  ligamentum  patellae.  The  affection  may  be  mis- 
taken for  inflammation  of  the  superficial  pretibial  bursa.  Careful 
examination  will  usually  differentiate  it  from  synovitis  of  the  knee- 
joint.  Tuberculosis  of  this  bursa  may  occur. 

The  treatment  does  not  differ  from  that  of  housemaid's  knee. 

The  inflammation  of  other  bursae  about  the  knee-joint  presents  no 
peculiar  symptoms,  and  the  existence  of  the  affection  is  made  evident 
by  the  presence  of  a  fluctuating  swelling  at  the  site  of  a  bursa. 

FRACTURES  AND  FISSURES  IN  THE  VICINITY  OF  JOINTS. 

Besides  fractures  directly  into  joints,  disabilities  and  deformities 
may  result  from  these  injuries  and  from  epiphyseal  separation  and 
fissures  in  the  close  vicinity  to  joints.  The  planes  of  the  joints  being 
altered  and  the  elasticity  of  the  joint  capsule  and  periarticular  tissues 
being  impaired  by  trauma  and  fibrous  cicatrization  and  thickening. 

This  condition  is  met  not  only  by  the  careful  apposition  of  the 
parts  in  case  of  fracture,  but  also  by  the  securing  of  the  limb  in  such  a 
position  as  will  furnish  useful  function  in  case  of  stiffness  and  by  the 
avoidance  of  too  long  fixation,  early  active  motion  being  permitted, 
at  first  under  careful  direction. 

In  injuries  of  this  sort  in  the  vicinity  of  the  shoulder,  care  should 
be  taken  to  secure  the  arm  at  first  in  a  slightly  abducted  position  by 
an  axillary  pad.  Marked  abduction  is  necessary  in  such  injuries  of 
the  hip.  In  the  elbow,  the  position  of  forced  flexion  is  often  desirable 
for  the  first  two  weeks  following  injury  (except  in  cases  of  fracture 
of  the  olecranon),  followed  by  fixation  in  the  right-angled  position. 
Front  foot  drop  is  to  be  prevented  in  injuries  of  the  ankle.  Flexion 
in  injuries  near  the  knee  is  to  be  prevented. 

Passive  motion  is  sometimes  needed,  but  it  should  be  borne  in 
mind  that  the  purpose  of  passive  motion  is  to  break  up  adhesions.  It 

1  Lovett  :  Boston  City  Hosp   Reports,  8th  series,  p.  345. 


154 


ORTHOPEDIC  SURGERY 


is  not  serviceable  in  restoring  elasticity  to  previously  torn  ligaments. 
This  is  to  be  accomplished  by  gradually  increasing  active  exercises, 
practiced  daily,  either  free  or  with  mechanical  aids,  the  simplest  of 
these  being  weight  and  pulley  appliances. 

Bursitis  of  the  shoulder  has  been  spoken  of  under  synovitis  of  that 
joint. 

ANKYLOSIS. 

Ankylosis  is  the  name  used  to  characterize  the  persistent  stiffness 
of  a  joint.  This  may  be  "  complete  "  when  all  motion  is  lost,  or 
"  partial  "  or  "  incomplete  "  when  some  part  of  the  normal  motion 


FIG.   1^9. — True  Ankylosis  of  the  Hip-joint.      (Toachimsthal.) 

remains.  It  is  also  classified  as  "  bony  "  or  "  fibrous  "  ankylosis,  ac- 
cording to  the  character  of  the  tissue  binding  together  the  joint  sur- 
faces. False  ankylosis,  pseudo-ankylosis,  etc.,  are  terms  used  to  desig- 


OTHER  AFFECTIONS  OF  THE  BONES  AND  JOINTS    155 

nate  a  condition  of  joint  stiffness  in  which  the  restriction  of  joint 
motion  is  due,  not  to  destruction  of  the  joint  surfaces,  but  to  other 
causes,  such,  for  example,  as  the  development  of  osteophytes  and  the 
like  around  the  edges  of  the  joint  occurring  in  arthritis  deformans, 


FIG.    130. — Pseudo-ankylosis  of   Hip-joint   Due  to  Arthritis   Deformans.      (Joachimsthal.) 

the  contraction  of  the  joint  capsule,  etc.  The  name  ankylosis  should 
not  be  applied  to  the  stiffness  of  joints  due  to  the  tonic  muscular  spasm 
of  acute  or  chronic  joint  disease.  This  disappears  under  anaesthesia, 
whereas  ankylosis  is  not  affected  by  it. 

The  pathology  of  ankylosis  is  the  pathology  of  the  affections 
which  cause  it.  It  represents  in  general  the  end  result,  the  cicatrix, 
of  an  acute  or  chronic  joint  inflammation  or  of  a  more  or  less  severe 
trauma. 

The  causes  of  acquired  ankylosis  are  therefore  to  be  found  in 
.acute  or  chronic  joint  inflammation,  in  the  ankylosing  form  of  arthritis 


156 


ORTHOPEDIC  SURGERY 


deformans,  in  fractures  involving  the  joints,  in  trauma  of  various 
kinds,  and  in  periarticular  suppuration  and  trauma.  The  fixation  of 
normal  joints  for  any  reasonable  time  does  not  cause  true  ankylosis. 
The  position  in  which  ankylosis  occurs  is  of  great  importance,  as  the 
usefulness  of  a  limb  in  cases  of  irremediable  ankylosis  will  depend 
on  stiffness  in  a  useful  position. 

The  desirable  position  for  ankylosis  of  the  hip  is  in  a  few  degrees 
of  flexion  with  no  adduction  or  abduction. 

In  the  knee  the  useful  position  is  with  the  leg  nearly  straight. 


FIG.    131. — True  Ankylosis  of  Hip-joint  Due  to  Tuberculous  Disease.      (Warren  .Museum.) 

In  the  ankle  the  desirable  position  for  a  stiff  joint  is  with  the  foot 
at  a  right  angle  to  the  leg. 

In  the  shoulder  the  arm  is  most  useful  if  slightly  abducted  and  a 
little  flexed. 

With  a  stiff  elbow  the  only  useful  arm  is  obtained  with  the  fore- 
arm at  a  right  angle  to  the  arm. 

The  diagnosis  of  ankylosis  is  made  by  the  absence  or  limitation  of 
motion.  It  is  not  diminished  by  anaesthesia,  and  in  true  ankylosis  the 
,r-ray  shows  the  disappearance  of  the  line  between  the  bones  and  the 


OTHER  AFFECTIONS  OF  THE  BONES  AND  JOINTS    157 

continuity  of  bony  structure  in  bony  ankylosis.  The  prevention  of 
ankylosis,  therefore,  consists  in  the  efficient  treatment  of  the  affections 
likely  to  cause  it. 

The  treatment  of  ankylosis  when  the  union  is  not  bony,  naturally 
differs  from  that  when  the  ends  of  the  joint  are  connected  by  bone. 
In  the  latter  case  non-operative  treatment  is  useless. 

In  incomplete  ankylosis  an  attempt  may  be  made  to  stretch  the 
connecting  structures  and  thus  increase  the  amount  of  motion. 

Manual  Stretching. — This  may  be  done  by  gradual  manual  stretch- 
ing, in  which  gentle  manipulative  force  is  used  at  short  intervals  and 
repeated  daily.  If  too  much  force  is  used,  inflammatory  reaction  will 
be  started  in  the  joint,  and  the  condition  will  be  made  worse.  The 
use  of  a  proper  degree  of  force  should  be  followed  by  a  daily  increase 
of  joint  motion  without  great  pain.  This  is  especially  the  case  after 
fractures  involving  the  joints. 

Mechanical  Correction. — The  attempt  at  stretching  may  be  made 
by  means  of  a  pendulum  apparatus,  in  which  a  carefully  controlled 
rhythmical  movement  is  exerted  to  any  desired  extent,  by  the  Zander 
apparatus,  or  by  the  use  of  manual  force. 

Bier's  congestive  method,  hot-air  baths,  massage,  and  vibratory 
massage  are  often  of  use  in  connection  with  the  measures  described, 
and  are  especially  suited  to  the  stiffness  following  fractures  and  joint 
injuries,  the  loss  of  motion  in  arthritis  deformans,  and  after  non- 
tuberculous  inflammations  in  and  around  the  joints. 

Forcible  Stretching. — In  case  these  measures  prove  ineffectual  the 
patient  should  be  anaesthetized  and  the  arc  of  motion  of  the  stiffened 
joint  increased  by  the  use  of  moderate  force  to  stretch  or  break  the 
adhesions  existing.  This  should  be  followed  by  rest  to  the  joint  for 
one  or  two  days,  followed  by  the  resumption  of  the  gentle  measures 
described.  The  injudicious  use  of  force,  as  a  rule,  does  more  harm 
than  good  by  exciting  inflammation  and  causing  new  adhesions.  After 
the  use  of  manipulative  force  the  joint  should  be  fixed  in  the  position 
of  greatest  usefulness,  described  above. 

In  bony  ankylosis,  if  the  ankylosis  has  occurred  in  a  position  of 
deformity,  the  joint  should  be  corrected  by  osteotomy  or  excision  and 
the  limb  placed  in  a  useful  position,  or  the  operative  attempt  should 
be  made  to  form  a  new  joint. 

Osteotomy  is,  as  a  rule,  linear,  and  is  generally  performed  just 
above  or  below  the  joint  surface.  Wedge-shaped  osteotomy  inevita- 
bly shortens  a  limb,  but  may  be  required  in  cases  of  extreme  deformity. 

Excision  may  be  done  at  the  site  of  an  ankylosed  joint,  not  with  a 


158  ORTHOPEDIC  SURGERY 

view  of  restoring  motion,  but  to  correct  deformity.  The  planes  of 
the  resected  ends  of  the  bones  should  be  so  placed  as  to  give  the 
desired  position  of  the  joint  after  union. 

Formation  of  New  Joints. — In  bony  ankylosis  the  formation  of  a 
new  joint  at  the  site  of  the  former  one  may  be  attempted.  The 
method  of  interposing  a  layer  of  fascia,  pig's  bladder,  several  layers  of 
Cargile  membrane,  or  other  foreign  substance  between  the  resected 
ends  of  the  bone  in  cases  of  true  bony  ankylosis  has  been  described 
and  successfully  carried  out  with  marked  success  by  certain  surgeons.1 
The  hope  of  success  in  the  operation  depends  upon  the  fact  that 
aponeurosis  attached  to  fatty  tissue  when  subject  to  pressure  tends 
to  form  an  hygroma  or  bursa.  If,  then,  the  line  of  union  where  the 
joint  formerly  existed  is  chiselled  or  cut  through  in  approximately 
the  original  joint  plane,  and  aponeurotic,  or  muscular,  and  fatty  tissue 
is  interposed,  there  is  hope  of  a  restoration  of  joint  motion  in  place 
of  the  former  bony  ankylosis.2  The  capsule  and  synovial  membrane, 
if  the  latter  remains,  are  extirpated  and  only  essential  bands  of  liga- 
ments are  left.  Bony  outgrowths  are  removed,  adherent  tendcns 
freed,  cicatricial  contractions  cut  out,  and  a  flap  of  the  desired  tissue 
is  taken  from  the  neighborhood  and  turned  in  between  the  ends  of 
the  bones.  This  flap  should  be  secured  to  the  edges  of  the  capsule  and 
is  left  attached  by  its  base.  Use  of  the  limb  is  at  first  painful,  and 
passive  motion  under  anaesthesia  may  be  required.  The  hip  and  elbow 
are  the  most  favorable  joints  for  this  operation,  and  the  knee,  on 
account  of  its  flat  articular  surfaces,  the  least  favorable. 

Numerous  miscellaneous  joint  affections  remain  for  consideration 
which  do  not  lend  themselves  well  to  classification.  They  will  there- 
fore be  considered  in  this  place. 

Bone  Defects. — The  filling  of  cavities  and  defects  in  bone  due  to 
various  causes  (congenital  or  from  osteomyelitis)  with  a  solid  sub- 
stance, or  one  which  becomes  solid,  is  a  problem  which  has  for  a  long 
time  attracted  the  attention  of  surgeons.  Of  the  many  measures  tried, 
a  few  are  worthy  of  consideration. 

Antiseptic  Wax. — This  method  is  as  follows :  Equal  parts  of  oil 
of  sesame  and  spermaceti  are  sterilized  in  a  water  bath,  and  later 
60  parts  of  this  are  mixed  with  40  of  iodoform,  which  gives  a  yellow- 
ish, brittle  wax,  melting  at  about  50°.  \Yhen  it  is  to  be  used  it  is 
heated  just  above  the  melting  point  and  constantly  stirred.3 

1  Murphy:  Trans.  Am.  Surg.  Assn.,  xxii.,  315  (with  literature).    Hoffa:  Zeitsch. 
f.  orth.  Chir.,  xvii.     Baer :  Am.  Jour.  Orth.  Surg.,  vii.,   I,  i. 

2  Murphy :   Annals  of   Surgery,   1913,  Ivii.,  593. 

3  Simmons :  Annals  of  Surgery,  January,  1911. 


OTHER  AFFECTIONS  OF  THE  BONES  AND  JOINTS    159 

This  depends  for  its  success  on  the  thorough  asepsis  of 
the  part  filled,  and  is  not  suited  to  bone  still  retaining  in  its 
tissue  septic  germs;  it  is  more  suited  to  small  cavities  with  firm 
walls. 

When  the  cavity  is  a  large  one  and  the  defect  due  to  an  inflam- 
matory process,  the  best  proceeding  is  to  remove  the  whole  diseased 
portion  of  the  bone,  including  the  hard  cortical  involucrum,  if  such 
exist,  leaving  the  periosteum.  This  should  be  carefully  cleansed  and 
wiped  with  alcohol  and  the  opposing  walls  stitched  and  pressed  to- 
gether. New  healthy  bone  will,  under  favorable  circumstances, 
develop,  furnishing  a  useful  limb. 

Bone  Grafting. — When  a  congenital  defect  of  bone  exists  or  in 
ununited  fractures  or  fractures  with  loss  of  substance  it  is  usually 
possible  to  repair  the  defect  by  the  transplantation  of  bone  from 
some  other  locality  in  the  individual,  but  preferably  not  from  the 
same  limb.  This  bone  may  be  fastened  in  its  new  place  by  being 
inserted  into  a  groove  in  the  bones  deep  enough  to  expose  endosteum, 
or  better  still  by  being  dowelled  into  the  ends  of  the  bones  which 
are  to  be  fastened  together.  It  is  still  a  disputed  point  as  to  how 
necessary  it  is  to  have  periosteum  on  the  graft,  but  in  the  present 
state  of  our  knowledge  it  seems  safer  to  transplant  periosteum 
with  bone.  The  transplantation  of  animal  bone  to  man  is  not  yet 
practical. 

As  has  been  demonstrated  by  clinical  experience  under  favorable 
conditions  and  laboratory  experiment,  firm  bone  is  secured  by  this 
procedure. 

Bone  Sinuses. — The  successful  treatment  of  these  depends  upon 
the  condition  of  the  original  source  of  origin  of  the  sinus. 

When  a  tuberculous  or  septic  ostitis  is  present  in  a  bone,  the 
resulting  sinus  is  a  channel  of  drainage  and  cannot  heal  as  long  as 
discharge  comes  from  the  original  source.  If  the  discharge  is  scanty 
the  sinus  may  heal,  but  as  the  discharge  accumulates  a  fresh  sinus 
forms. 

The  cure  in  this  condition  consists,  when  this  is  possible,  in  the 
treatment  of  the  original  ostitis,  either  by  drainage  with  disinfection 
or  removal  of  dead  bone. 

In  some  instances  the  sinus  remains  unhealed,  owing  to  the  infec- 
tion of  the  walls  of  the  sinus  after  the  original  ostitis  has  healed. 
This  condition  can  sometimes  be  relieved  by  dilatation  of  the  sinus 
and  the  disinfection  of  the  walls  by  antiseptic  injection,  iodoform 
bougies,  etc.  Another  method  is  to  secure  complete  drainage  of  the 


i6o  ORTHOPEDIC  SURGERY 

sinus  by  applying  suction  cups  daily  and  thereby  promoting  complete 
evacuation  and  healing  through  the  cohesion  of  the  sinus  walls. 

Fragilitas  ossium.1 — Idiopathic  osteopsathyrosis  and  osteogenesis 
imperfecta.  also  known  as  fragilitas  ossium  and  brittle  bones,  are  con- 
ditions in  which  multiple  fractures  occur  in  young  children,  and  some- 
times in  such  cases  persist  through  life.  The  condition  is  at  times 
inherited  and  its  etiological  relations  are  obscure.  Union  as  a  rule 
occurs  readily  and  pathological  investigation  has  shown  the  conditions 
to  be  apparently  distinct  from  rickets  and  chondrodystrophy.  No  sat- 
isfactory treatment  has  been  formulated. 

OSTEOMALACIA. 

Osteomalacia  is  a  process  somewhat  similar  to  rickets  in  causing 
softening  of  the  bones,  the  etiological  and  pathological  relation  of 
which  to  rickets  is  at  present  much  discussed  and  very  imperfectly 
formulated,  but  the  pathology  of  which  is  different  from  that  of 
rickets.  There  is  absorption  of  the  lime  salts,  beginning  in  the  mar- 
row of  the  bone  and  affecting  first  the  spongiosa,  and  the  resistance 
of  the  bone  is  so  impaired  that  it  bends  or  breaks.  The  disease  is 
most  prevalent  among  the  lower  classes,  affecting  certain  localities 
more  than  others,  and  females  are  attacked  more  often  than  males. 
The  affection  as  described  affects  adolescents  and  adults  rather  than 
children. 

The  symptoms  consist  of  dull  pain  and  perhaps  tenderness  in  the 
affected  parts,  hypenesthesia  of  the  skin,  and  discomfort  in  walking 
or  sitting.  This  is  followed  or  accompanied  by  yielding  of  the  bones 
and  fractures,  complete  or  incomplete. 

The  treatment  of  the  disease  must  be  directed  to  the  relief  of 
the  symptoms  and  must  be  conducted  on  general  principles. 

CHONDRODYSTROPHIA   FCETALIS. 

Achondroplasia  ( foetal  rickets). — Although  this  condition  is  de- 
scribed frequently  under  the  name  of  "  foetal  rickets/'  it  is  essentially 
a  different  pathological  process.  Clinically  the  children  at  birth  seem 
to  present  the  signs  of  a  severe  grade  of  rickets  which  has  run  its 
course.  The  head  is  large  and  the  bridge  of  the  nose  depressed. 
There  is  beading  of  the  ribs  and  perhaps  flattening  of  the  sides  of  the 
chest,  and  the  long  bones  of  the  extremities  are  shortened  and  perhaps 
bowed  and  enlarged  near  the  joints. 

The  essential  pathological  process  is,  however,  a  disturbance  of 

:  Zeitsch.  f.  orth.  Chir.,  xxvii.,  i  and  2,  1.15. 


OTHER  AFFECTIONS  OF  THE  BONES  AND  JOINTS    161 

the  normal  process  of  ossification  of  the  primary  cartilage.  The 
cartilage  atrophies  and  the  process  of  ossification  takes  place  abnor- 
mally early.  In  true  chonclrodystrophia  the  bones  will  remain  dis- 
torted, the  joints  will  probably  be  limited  in  their  range  of  motion, 
and  the  general  growth  of  the  body  retarded,  resulting  in  dwarfism. 
The  milder  cases  may  reach  adult  life.  The  treatment  can  only  be 
palliative. 

HABITUAL   OR   RECURRENT   DISLOCATIONS. 

Patella. — Dislocation  of  the  patella  or  slipping  patella  is  like  to 
occur  either  spontaneously  or  for  very  slight  cause  in  certain  young 

girls  with  lax  muscular  fibre  and  a 
feeble  development.  Boys  are  only  ex- 
ceptionally attacked. 

In  consequence  of  some  slight  twist 
of  the  leg,  as  in  dancing,  rising  from 
a  chair,  going  upstairs,  or  some  similar 
motion,  an  excruciating  pain  is  felt  in 
the  knee,  and  the  person  either  falls  in 
consequence  of  faintness  or  finds  her- 
self unable  to  use  the  leg.  The  patella 
is  found  almost  always  dislocated  out- 
wardly, sometimes  twisted  so  that  its 
lateral  edge  rests  against  the  front  of 
the  femur.  The  reduction  of  the  dislo- 
cation is  very  simple  and  is  very  soon 
learned  by  the  patients  themselves. 
The  leg  is  fully  extended  and  the  pa- 
tella gently  pressed  back  into  place 
until  it  assumes  its  proper  place  with 
a  click,  or  often  it  slips  back  of  its  own 
accord  when  the  leg  is  straightened. 
An  attack  of  synovitis  follows,  as  in 
the  case  of  loose  bodies,  but  the  joint 
soon  acquires  a  tolerance  so  that  each 
succeeding  attack  of  synovitis  becomes 
less.  The  cause  of  the  affection  seems 
to  be,  in  most  cases,  the  lack  of 
tonicity  in  the  extensor  muscles  of  the  thigh,  or  the  elongation  of  the 
ligamentum  patellae. 

After  many  attacks  of  dislocation  the  patients  complain  of  a  cer- 


FIG.    132. — Chondrodystrophia   Foeta- 
lis,    "  Congenital   Rickets." 


1 62 


ORTHOPEDIC  SURGERY 


tain  sense  of  insecurity  in  walking,  which  in  severe  cases  may  amount 
to  a  distressing  disability,  limiting  the  patient's  ability  to  walk  or 
engage  in  active  occupation. 

Mechanical  Treatment. — If  an  elastic  knee-cap  is  split  in  front  and 
furnished  with  lacings  or  straps,  and  if  felt  pads  are  sewed  upon 
the  sides  of  the  cap  at  such  places  as  would  exert  pressure  upon  the 


FIG.   133. — Dislocation  of  Patella. 

sides  of  the  patella,  an  arrangement  is  furnished  which,  when  properly 
adjusted,  will  give  a  serviceable  support  in  lighter  cases,  allowing 
motion  at  the  knee. 

Some  retentive  apparatus,  along  with  the  use  of  massage  and 
exercise,  may  effect  a  cure,  especially  in  rapidly  growing  girls. 

Operative  Treatment. — In  resistant  cases,  or  those  unable  to  fol- 
low out  proper  mechanical  treatment,  operation  will  be  required.1 

This  consists  in  the  removal  of  an  elliptical  piece  of  the  front  of 
the  capsule  of  the  joint  internal  to  the  extensor  tendon  and  a  stitching 
together  of  the  edges  of  the  opening,  thereby  tightening  the  inner 

1Bade  :  Zeit.  f.  orth.  Chir.,  xi. ,  3,  451  (with  bibliography). 


OTHER  AFFECTIONS  OF  THE  BONES  AND  JOINTS    163 

part  of  the  capsule.1  In  resistant  cases  a  vertical  incision  outside  of 
the  patella  tendon  must  also  be  made  to  allow  the  patella  to  be  pulled 
into  place  by  the  tightening  of  the  capsule  on  the  inner  side.  The 
tubercle  of  the  tibia  may  be  transplanted  2  farther  in  on  the  tibia, 
or  the  patella  tendon  may  be  split  longitudinally  and  the  inner  half 
carried  under  the  outer  and  attached  to  the  tibia  outside  of  the 
tubercle.3 

Habitual  or  recurrent  dislocation  of  the  shoulder  becomes  at  times 
an  affection  requiring  orthopedic  treatment. 

The  causes  of  the  condition  may  be  formulated  as  follows :  i.  Lax- 
ity of  the  capsule  of  the  joint.  2.  Partial  fracture  of  the  head  of  the 
humerus.  3.  Partial  fracture  of  the  glenoid  cavity.  4.  Tearing  away 
of  muscular  insertions  and  rupture  of  tendons.  5.  Abnormality  in 
the  shape  of  the  head  of  the  humerus  not  demonstrably  due  to  fracture. 
It  would  seem  as  if  in  certain  instances  the  cause  of  the  recurrence 
of  the  dislocation  was  insufficient  immobilization  of  the  arm  after  a 
primary  dislocation.  Reduction  is  as  a  rule  easy,  and  inflammatory 
reaction  in  the  joint  is  notably  slight  or  even  wholly  absent  after 
reduction. 

Prognosis. — In  a  shoulder-joint  in  which  a  dislocation  has  twice 
occurred,  the  second  time  from  insufficient  cause,  it  is  not  likely  that 
the  liability  will  become  less  frequent  as  time  advances  if  no  treatment 
is  undertaken.  As  a  rule,  the  dislocations  will  occur  with  greater 
frequency  and  from  slighter  causes  as  time  progresses. 

Treatment. — The  methods  of  treatment  are : 

By  apparatus ;  by  massage  and  exercises  alone ;  by  temporary  fixa- 
tion and  massage;  by  operation. 

The  use  of  apparatus  confining  the  arm  to  the  side  is  to  be  con- 
demned. 

Fixation  for  some  time  is  called  for  when  a  second  dislocation  has 
occurred  from  slight  cause.  The  arm  is  lifted  by  applying  a  sling, 
which  supports  the  forearm  and  point  of  the  elbow.  The  arm  is  held 
to  the  side  by  a  swathe,  thus  preventing  all  motions  of  the  joint. 
This  removes  as  much  weight  as  possible  from  the  joint  capsule. 

Such  cases  have  been  operated  upon  successfully  by  reefing  the 
anterior  part  of  the  capsule  of  the  joint  through  an  anterior  incision.4 

1  N.  Y.  Med.  Record,  April  20,  1895.— Trans.  Am.  Orth.  Assn.,  vol.  viii.,  p.  227. 
— Ibid.,  vol    viii., p.  237. 

2  Annals  of  Surg.,  1899. 

8Goldthwait :  Am.  Journ.  Orth.  Surgery,  vol.  i.,  No.  3. 
4Burrell  and  Lovett  :  Am.  Jour.  Med.  Sciences,  August,  1897. 


1 64  ORTHOPEDIC  SURGERY 

Sacro-Iliac  Articulation. — This  articulation,  under  ordinary  cir- 
cumstances, is  a  true  joint,  but  permits  a  degree  of  motion  so  small 
that  it  is  scarcely  measurable.  In  pregnancy,  along  with  the  joint  of 
the  symphysis  pubis,  it  becomes  somewhat  relaxed  to  facilitate  de- 
livery, and  occasionally  this  relaxation  reaches  a  degree  which  gives 
rise  to  backache  and  makes  walking  difficult  or  even  impossible  in 
the  later  days  of  pregnancy.  After  delivery  the  relaxation,  as  a 
rule,  disappears  spontaneously,  but  it  may  persist  for  a  while,  giving 
rise  to  a  difficult  gait  and  a  feeling  of  instability.  Such  symptoms 
are  treated  by  the  use  of  a  leather  or  other  corset  fitting  tightly 
around  the  sacrum  and  ilia  and  by  the  limitation  of  walking  with 
perhaps  the  use  of  crutches. 

The  assumption  that  this  joint  frequently  becomes  relaxed  or 
subluxated  under  other  conditions  (such  as  faulty  attitude,  slight 
strains,  etc.)  and  is  the  source  of  chronic  backache  is  not  supported 
by  .r-ray,  clinical,  or  pathological  evidence. 

Although  crushing  force  may  cause  such  dislocation,  but  gen- 
erally in  connection  with  fractures  of  the  pelvis. 


TUMORS    OF    THE    BONES    AND    JOINTS. 

Primary  tumors  of  bone  belong  to  the  group  of  connective-tissue 
tumors.  The  periosteum  and  bone  marrow  form  the  matrix  for  their 
development.  These  tumors  correspond  to  the  various  types  of  con- 
nective tissue,  fibrous,  mucoicl,  cartilaginous,  and  osseous.  Among 
primary  tumors  are  to  be  classed  sarcomata.  Secondary  tumors  of 
any  kind  may  occur,  among  the  latter  being  carcinoma.  Angioma, 
hsematoma,  echinococcus  cyst,  and  aneurism  must  be  mentioned  as 
other  possibilities. 

MALIGNANT  DISEASE  OF  THE  SPINE. 

Sarcoma  and  carcinoma  of  the  vertebral  column  are  occasionally 
tnet.  Carcinoma  has  been  noted  following  similar  disease  of  the 
breast  and  testicle,  and  less  frequently  of  the  stomach.  The  disease 
usually  begins  as  an  infiltration  of  the  spongy  tissue  of  the  vertebral 
bodies,  which  is  gradually  replaced  by  the  malignant  growth.  There 
may  be  but  little  change  in  the  appearance  of  the  bodies,  but  these 
will  be  found  converted  into  a  soft,  friable  mass.  Destruction  of  the 
bone  substance  with  deformity  may  occur.  The  most  frequent  site 
of  malignant  disease  is  in  the  lumbar  region,  and  the  next  commonest 
location  is  in  the  dorsal  vertebrae. 


OTHER  AFFECTIONS  OF  THE  BONES  AND  JOINTS    165 

The  symptoms  are  similar  to  those  of  Pott's  disease,  pain  being 
very  prominent,  with  frequently  paralysis. 

When  deformity  occurs  it  will  be  found  to  present  a  more  rounded 
prominence  than  is  usually  seen  in  Pott's  disease.  When  following 
malignant  disease  elsewhere,  which  can  be  recognized,  the  diagnosis 
should  present  no  special  difficulty,  but  in  other  instances  it  is  usually 
hard  or  even  impossible.  The  prognosis  needs  no  comment. 

MALIGNANT  DISEASE  OF  THE  HIP. 

The  variety  of  tumor  which  most  often  affects  the  head  of  the 
femur  in  young  children  is  a  round-cell  sarcoma  of  the  periosteum, 
but  the  epiphysis  is  rarely  the  seat  of  the  tumor. 

The  early  symptoms  in  cases  in  which  the  head  of  the  femur  is  not 
primarily  involved  are  very  slight,  and  consist  chiefly  of  a  swelling 
which  is  painless  and  not  fluctuating;  limp  and  slight  restriction  of 
motion  may  be  present.  Soon,  however,  it  becomes  evident  that  the 
enlargement  is  predominating  over  all  the  other  symptoms  and  the 
swelling  progressively  increases,  suggesting  perhaps  hip  abscess. 
Fluctuation,  however,  is  absent  and  the  swelling  embraces  the  whole 
circumference  of  the  limb.  There  is  an  enlargement  of  the  superficial 
vessels  and  the  swelling  later  becomes  enormous.  The  patient  becomes 
emaciated  and  wastes  away.  The  affection  may  be  very  painful  or 
again  it  may  be  attended  with  very  little  suffering.  According  to 
the  histological  character  of  the  tumor  the  treatment  would  consist 
in  the  removal  of  the  growth,  followed  by  the  use  of  toxines  or  in 
amputation  at  the  hip-joint.  The  statistics  are  not  favorable  to  am- 
putation as  a  means  of  cure. 

SYPHILIS  OF  THE  BONES  AND  JOINTS. 

Syphilis  may  attack  either  the  bones  or  the  joints,  and  as  the 
bone  lesions  are  the  more  important  on  account  of  their  frequency 
they  will  be  considered  first. 

SYPHILIS  OF  THE  BONES. 

Congenital  Syphilis. — Congenital  syphilis  may  be  evident  in  the 
fetus,  at  birth  or  later.  The  commonest  occurrence  of  syphilis  is 
manifested  in  osteochondritis,  which  in  its  severer  forms  is  the 
cause  of  the  pseudo-paralysis  of  Parrot.  This  lesion,  which  is 
characteristic  and  is  said  to  be  constant,  occurs  along  the  line  of 


i66 


ORTHOPEDIC  SURGERY 


ossification  in  the  long  bones.     The  process  of  ossification  is  delayed 
with  broadening  of  the  cartilaginous  layer. 

Macroscopically  the  normal  narrow  line  of  ossification  becomes 
a  broad  yellowish  white  line  which  fades  out  toward  the  diaphysis. 


FIG.   134.— X-Ray  Showing  Localized 
Syphilitic  Gumma  of  Bone. 


FIG.   135. — X-Ray    Showing    Periosteal   Thickening    Due  to 
Syphilis. 


Clinically  it  is  manifested  by  thickening  of  bone  at  the  epiphyseal 
line  or  above  it,  tenderness,  and  occasional  joint  inflammation. 

It  is  essentially  an  affection  of  young  children,  and  resembles  the 
epiphyseal  disturbances  of  rickets.  It  affects  most  often  the  knees, 
ankles,  and  elbows  in  the  order  named. 

On  examination  of  the  affected  area  one  finds  a  regular  deposition 
of  bone,  and  in  the  spaces  there  develops  a  gray  yellow  granulation 
tissue,  which  destroys  the  bone  trabeculse,  and  in  the  severer  cases 
tends  to  separate  the  epiphysis.  In  the  .i--ray  it  appears  as  a  homo- 


OTHER  AFFECTIONS  OF  THE  BONES  AND  JOINTS     167 

geneous  transverse  band  of  shadow  serrated  toward  the  diaphysis,  or 
a  striated  band,  both  casting  less  shadow  in  the  plate  than  the  normal 
part  of  the  epiphysis. 

The  other  common  form  of  congenital  syphilis  is  syphilitic  ossi- 
fying periostitis.  This  occurs  most  often  in  the  shaft  of  the  long 
bones  of  the  lower  leg,  but  may  affect 
the  other  bones,  and  consists  of  a  cov- 
ering of  subperiosteal  newly  formed 
bone,  generally  more  marked  in  the 
middle  of  the  shaft  than  at  the  ends. 
The  original  bone  is  generally  intact, 
but  may  be  invaded.  In  its  most  fre- 
quent form  it  is  the  well-known  sabre 
tibia,  which  shows  a  curve,  with  dis- 
tinct thickening  of  periosteum  on  the 
anterior  border.  This  process  is  ac- 
companied often  by  lengthening,  and 
curving  of  the  leg  forward.  Thicken- 
ing of  the  phalanges,  known  as  dacty- 
litis,  is  likely  to  accompany  this.  Hutch- 
insonian  teeth  are  likely  to  be  present. 

Acquired  Syphilis. — In  the  sec- 
ondary stage  a  syphilitic  periostitis  is 
to  be  recognized.  Pathologically  this 
consists  of  a  gelatinous  tissue  formed 
in  the  inner  periosteal  layer,  with  an 
indentated  growth  into  enlarged  Ha- 
versian  canals  of  the  bone. 

To  the  tertiary  stage  of  acquired 
syphilis  belong — 

1 i )  Circumscribed  periostitis. 

(2)  Diffuse  periostitis. 

Lccal  gummatous  osteomye- 
litis. 

Diffuse  gummatous  osteo- 
myelitis. 

Dactvlitis. 


(3) 
(4) 


(5) 


FIG.  136. — Illustrating  Double  Synovitis 
of  Knee  in  Congenital  Syphilis. 


In  circumscribed  periostitis  the  gummatous  new  formation  ex- 
tends into  the  cortex,  and  finally  the  marrow,  and  eats  into  the  bone 
irregularly,  sometimes  causing  a  flat  sequestrum  and  sometimes  lead- 
ing to  periosteal  formation.  A  part  of  the  gumma  breaks  down,  and 


if,S  ORTHOPEDIC  SURGERY 

is  absorbed  or  forms  pus.  The  end  result  is  a  local  carious  destruc- 
tion of  the  bone,  with  thickening  of  the  bone  around  it. 

In  diffuse  periostitis,  affecting  most  often  the  tibia,  the  whole 
bone  is  involved,  and  is  gradually  thickened,  especially  along  the  ante- 
rior part,  by  a  great  number  of  hyperostoses,  which  lie  near  each  other 
and  coalesce  to  thicken  the  cortex  to  two  or  three  times  its  normal 
depth.  The  bone  becomes  thicker  in  this  area,  and  apparently  curved. 

Of  dactylitis  there  are  two  forms — one  beginning  in  the  central 
gumma,  the  other  in  periosteal  overgrowth. 

All  of  these  lesions  are  more  likely  to  be  symmetrical  than  those 
of  tuberculosis,  ostec  myelitis,  or  new  growths.  The  symptoms  are 
those  of  a  slowly  progressing  affection,  accompanied  by  tenderness 
over  the  affected  area  and  local  bone,  worst  at  night.  There  is  rela- 
tively little  fever.  The  diagnosis  is  as  a  rule  difficult,  and  in  the 
present  stage  of  our  knowledge  it  is  impossible  to  recognize  in  many 
cases  whether  the  disease  is  tuberculosis,  osteomyelitis,  or  syphilis. 
With  the  improvement  of  our  knowledge  it  is  now  possible  to  recog- 
nize many  more  cases  of  syphilitic  bone  disease  than  was  the  case 
some  years  ago,  but  it  must  be  recognized  that  knowledge,  even 
to-day,  is  very  imperfect.  The  .r-ray  is  of  much  diagnostic  value, 
and  the  Wasserman  reaction  when  positive  is  of  great  help,  but  it 
must  be  remembered  that  a  negative  \Yasserman  reaction  does  not 
exclude  syphilis  in  either  the  congenital  or  the  acquired  form.  De- 
formities may  result  in  the  way  of  spontaneous  fractures  at  the  site 
of  bone  gummata,  bowing  of  the  long  bones,  as  exemplified  in  the 
sabre  tibia,  knock-knee  and  bow  legs  as  the  result  of  epiphyseal  dis- 
turbances, and  other  deformities  of  the  joints  frcm  epiphyseal  separa- 
tions, the  result  of  early  osteochondritis. 

The  treatment  is  obviously  the  use  of  anti-syphilitic  measures  and 
the  later  operative  correction,  when  necessary,  of  residual  deformities. 

SYPHILIS  OF  THE  JOINTS. 

Syphilitic  joint  disease  and  congenital  syphilis  are  most  often 
manifested  by  a  symmetrical  synovitis  of  the  knees,  also  affecting 
at  times  the  feet  and  hands.  There  is  a  swelling  of  the  joints,  the 
capsule  is  thickened,  with  generally  some  fluid,  and  the  whole  con- 
dition is  like  the  tuberculous  hydrops,  but  it  is  symmetrical  and  not 
especially  painful.  There  is  not  much  limitation  of  motion,  and  the 
jr-ray  appearances  are  apparently  negative  as  to  the  joints,  but  may 
show  periosteal  changes  in  the  tibia  or  other  bones.  In  adults  it  is 
not  so  svmmetrical  as  in  children,  and  mav  resemble  even  more 


OTHER  AFFECTIONS  OF  THE  BONES  AND  JOINTS     169 

closely  the  synovitis  of  tuberculosis.  X-ray  appearances  in  the  sym- 
metrical knee  synovitis  of  children  are  negative  in  the  early  stages, 
although  the  joint  may  be  seen  to  be  surrounded  by  a  cloud.  The 
conjunction  of  interstitial  keratitis  with  this  knee  affection  is  of  much 
diagnostic  significance,  and  is  very  common.  It  may  occur  appar- 
ently without  other  manifestations,  but  more  ccmmonly  in  connection 
with  syphilitic  bone  manifestations.  In  some  cases  the  joints  are 
involved  in  syphilis  secondarily  to  a  bone  infection,  in  which  case 
foci  of  the  kind  described  under  the  head  of  "  syphilis  of  the  bones  " 
are  to  be  found  in  the  epiphyses  which  have  secondarily  involved  the 
articular  structures. 

GOUT. 

The  joint  affection,  which  is  the  manifestation  of  the  constitutional 
malady  known  as  gout,  ordinarily  begins  as  an  acute  attack,  and  is 
followed  by  a  chronic  inflammatory  process,  increased  by  constant 
exacerbations.  The  synovial  membrane  first  presents  the  appearances 
of  acute  inflammation;  the  cartilage  also  shows  a  tendency  to  inflam- 
matory degeneration  and  erosion,  and  on  its  free  surface  and  in  its 
tissue,  as  well  as  in  its  capsule  and  periarticular  structure,  there  appears 
a  deposit  of  acicular  crystals  of  urate  of  soda,  which  localized  de- 
posits are  known  as  "  tophi."  There  is  a  permanent  thickening  of 
the  synovial  membrane.  There  is  but  little  tendency  to  suppuration, 
unless  the  calcareous  deposits  ulcerate  through  the  skin  by  pressure 
and  so  open  the  periarticular  tissue.  The  common  seat  of  the  affec- 
tion is  the  metatarsophalangeal  joint  of  the  great  toe  (podagra).  The 
joints  of  the  hands,  and  the  knee-  and  elbow-joints  are  also  often 
affected. 

OSTITIS   DEFORMANS. 

Paget's  Disease. — This  name  designates  a  deformity  affecting 
the  long  bones,  chiefly  in  their  diaphyses,  causing  them  to  bend.  It 
most  frequently  attacks  the  lower  extremities  first,  also  involving  the 
spine  and  the  skull.  The  upper  extremities  are  at  times  curved.  The 
process  consists  of  a  thickening  and  curving  of  the  affected  bones, 
the  bone  hypertrophying  as  a  whole  and  its  curves  increasing,  while 
the  external  surface  is  roughened.  In  most  cases  the  enlargement 
takes  place  by  the  expansion  of  the  cortex;  in  other  cases  the  spongy 
part  of  the  bone  is  extended.  The  skull  shows  marked  thickening 
and  enlargement. 


170 


ORTHOPEDIC  SURGERY 


Microscopic  examination  shows  appearances  of  absorption  and 
new  formation,  and  the  proportion  of  minerals  salts  in  the  bcnes  is 
diminished. 

Etiology. — In  the  matter  cf  etiology  nothing  definite  has  been 
established.  The  disease  attacks  men  in  middle  adult  life  more  fre- 
quently than  women.  The  relation  cf  the  disease  to  arterioscle- 
rosis is  obscure,  seme  writers  claiming  that  pathologically  they 
are  identical.  This  point  of  view  cannot  yet  be  regarded  as  estab- 
lished. 

Symptoms. — The  affection  is  generally  ushered  in  by  a  long  period 
cf  pain  described  as  "  rheumatic,"  and  perhaps  by  headaches.1  Seme 

cases  are,  however,  practi- 
cally painless.  The  general 
condition  of  the  patient  is 
often  not  seriously  affected. 
The  attitude  is  character- 
istic; in  advanced  cases  the 
patient  stands  with  the  legs 
bowed  and  the  spine  bent  in 
a  gradual  backward  curve; 
the  body  may  be  carried  for- 
ward bent  at  the  hips,  the 
skull  may  be  greatly  en- 
larged, and  the  spine  lose  its 
flexibility.  In  such  cases  the 
bcdy  is  shortened  in  the 
erect  position.  The  diagnostic  symptoms  are  the  occurrence  of  bow- 
legs  beginning  in  the  latter  half  of  life,  the  bending  backward  of  the 
spine,  the  hypertrophy  of  the  bones,  and  especially  the  great  thickening 
of  the  skull.  Fractures  occur  rarely,  and  in  cases  observed  have  united 
readily. 

Prognosis. — The  prognosis  of  the  affection  as  far  as  life  goes  is  not 
unfavorable,  and  death  generally  occurs  from  intercurrent  affections. 
Xo  satisfactory  treatment  has  been  formulated.  Protective  apparatus 
in  the  severer  deformities  may  be  necessary,  but  they  increase  muscular 
weakness  and  are  to  be  avoided  if  possible. 

PATHOLOGICAL   CONDITIONS    OF  THE   NERVOUS   SYSTEM. 

Charcot's  joint  disease,  spinal  or  neuropathic  arthropathy,  neural 
arthropathy,  tabetic  arthropathy,  etc. 

1  \\ollenberg :  Zeitsch.  f.  orth.  Chir.,  xiii.,  i. 


I-'IG.   137. — Knee-joint    Surfaces    in    Gout,    Showing 
Deposits. 


OTHER  AFFECTIONS  OF  THE  BONES  AND  JOINTS     171 

A  destructive  form  of  joint  disease  may  be  associated  with  locomo- 
tor  ataxia,  syringomyelia,  Pott's  disease,  acute  myelitis,  injuries  of 
the  peripheral  nerves,  cerebral  apoplexy,  tumors  of  the  cord,  crushing 


FIG.  138.— Ostitis  Deformans.  Male,  age  fifty-four.  First  definite  signs  seven  years  before 
photograph.  Present  involvement  most  marked  in  cranium,  clavicles,  right  ulna,  left 
radius,  pelvis,  tibiae,  and  fibix.  (R.  B.  Osgood.) 


of    the    spinal    cord,  progressive    muscular    atrophy,    and    anterior 
poliomyelitis. 

The  pathological  process  is  in  many  respects  similar  to  that  in 
arthritis  deformans,  except  that  the  destructive  process  is  more  rapid 


172 


ORTHOPEDIC  SURGERY 


and  the  formative  activity  less.  This  process  may  result  in  spontane- 
ous luxation  in  severe  cases.  Synovial  effusion  may  be  present,  and 
suppuration  may  occur.  The  essential  character  of  the  affection  is 
the  rapid  melting  away  of  cartilage  and  bones,  and  the  joint  changes 
may  be  present  at  an  early  stage  of  the  nervous  disorder. 


FIG.  139.— Charcot's  Disease  of  Right  Knee-joint.      (Weigcl.) 

The  affection  is  most  often  monarticular,  and  adults  are  generally 
affected.  The  joints  are  affected  in  approximately  the  following  order 
of  frequency :  knee,  hip,  shoulder,  tarsus,  elbow,  ankle,  wrist,  jaw, 
and  spine. 

Swelling,  effusion,  disability,  and  sometimes  pain  are  the  first 
signs  of  the  joint  involvement.  Spontaneous  arrest  of  the  process 
may  occur,  and  ankylosis  may  rarely  result,  but  more  commonly  the 
joint  is  disorganized  to  the  point  of  luxation.  The  diagnosis  is  often 
difficult,  especially  in  the  early  stages. 


OTHER  AFFECTIONS  OF  THE  BONES  AND  JOINTS     173 

The  treatment  does  not  differ  essentially  frcm  that  cf  inflamed 
joints  in  general.  Although  excision  of  the  joint  has  been  success- 
fully done  under  these  conditions,  local  operative  measures  are  n:t, 
as  a  rule,  to  be  advised.  In  cases  in  which  there  is  evidence  c  f 
syphilis,  proper  treatment  should  be  given. 

Arthropathy  of  the  vertebral  column  has  been  rarely  observed  in 
tabes.  It  is  manifested  by  a  deformed  position  of  the  column,  shown 
by  scoliosis  and  backward  bending  of  the  spine.1  Partial  relief  may 
be  afforded  by  fixation. 

Arthropathy  of  the  Hip. — As  in  most  ether  instances,  Charcot's 
disease  of  the  hip  simulates  very  closely  arthritis  defcrmans  of  the 
ordinary  type.  The  changes  in  the  joint  are,  however,  much  more 
acute  and  extensive  than  those  with  which  we  are  familiar  in  arthritis 
deformans.  Rest  is  indicated  for  the  joint,  with  traction  if  it  gives 
relief. 

HEMOPHILIA. 

Haemophilia  is  accompanied  at  times  by  characteristic  joint  lesions, 
which  in  their  clinical  resemblance  to  tuberculosis  are  worthy  of  no- 
tice.2 The  knee  is  the  joint  most  frequently  affected.  Like  ether 
manifestations  of  this  diathesis,  joint  affections  occur  most  often  in 
male  children  or  young  adults,  decreasing  in  frequency  with  increasing 
age.  The  hemorrhage  may  be  intraarticular  or  periarticular.  After 
repeated  acute  attacks  cf  hemorrhage  into  the  joint,  chronic  joint 
changes  are  likely  to  ensue.  There  is  an  overgrowth  of  brown-stained 
synovial  tufts.  The  cartilage  may  degenerate,  and  sharp-bordered 
defects  in  it  are  frequently  found.  Adhesions,  contractions  of  the 
capsule,  and  bony  displacements  may  occur.  Erosion  cf  the  ends  of 
the  bones  may  take  place  along  with  a  proliferation  at  the  edges  not 
unlike  arthritis  deformans.  Rheumatic  pains  are  a  ccmmon  clinical 
accompaniment  of  the  affection,  and  its  character  is  essentially  chronic. 
Swelling  and  muscular  spasm  are  present  during  attacks  of  irritation, 
and  the  diagnosis  from  tuberculosis  is  to  be  made  more  from  the 
history  than  from  any  characteristic  features.3 

General  treatment  offers  but  little  hope,  although  the  use  of  gelatin 
by  mouth,  in  doses  of  six  or  more  ounces  daily,  has  been  found  of 
use,  and  thyroid  extract  has  been  reported  as  controlling  hemorrhage 
in  such  cases.4 

1  Spiller :  Am.  Medicine,  November  i,  1902,  p.  701  (with  bibliography). — Graet- 
zer :  Deutsch.  med.  Woch.,  December  24,  1903. 

2  Carless  (with  analysis  of  25.3  reported  cases)  :  Practitioner,  1903,  Ixx.,  85. 
"Gocht:  Munch,  med.  Woch.,  1899,  February  21,  271. 

4  J.  T.  Rugh :  Ann.  of  Surg.,  May,  1907. 


174  ORTHOPEDIC  SURGERY 

Protection  to  the  diseased  joints  is  of  mere  use  than  any  other 
one  measure,  but  the  prognosis  as  to  recovery  is  doubtful  at  best. 
Aspiration  with  a  small  needle  may  be  safely  done  for  purposes  of 
diagnosis.  Fatal  hemorrhages  have  occurred  as  the  result  of  opera- 
tion on  these  supposedly  tuberculous  joints. 


SCURVY. 

Joint  affections  in  infantile  scurvy  are  not  uncommon,  and  simu- 
late closely  epiphysitis.  The  enlargement  may  be  confined  to  one  of 
the  bones  forming  an  articulation.  The  thickening  is  due  to  periarticu- 
lar  or  rather  subperiosteal  hemorrhage,  and  the  joint  itself  is  not 


FIG.   140. — Secondary   Osteo-arthropathy   Due  to   Pott's   Disease,    Showing   Enlargement  of   Liver 

and  Spleen. 

usually  affected,  though  hemorrhage  may  occur.     Such  joints  yield 
readily  to  the  usual  treatment  of  infantile  scurvy. 


SECONDARY    HYPERTROPHIC   OSTEO-ARTHROPATHY. 

This  is  the  name  given  to  a  condition  occurring  sometimes  in  con- 
nection with   chronic   pulmonary   disease,   in   which   the   fingers   are 


OTHER  AFFECTIONS  OF  THE  BOXES  AND  JOINTS    175 

clubbed  and  stiffened,  the  shafts  of  the  bones  are  thickened,  and  the 
spine  is  bent  forward  in  a  kyphosis.  It  occurs  sometimes  in  connec- 
tion with  Pott's  disease.  The  relation  of  the  affection  to  acromegaly 
and  osteomalacia  is  not  clear.1 


ACTINOMYCOSIS. 

Actinomycosis  is  a  specific  infectious  disease  occasionally  attack- 
ing the  bone  secondarily,  and  is  caused  by  the  streptothrix  actinomy- 
cotica  (ray  fungus).  The  process  in  the  bone  is  a  destructive  one. 

The  spinal  column,  ribs,  and  sternum  may  be  attacked,  but  the 
maxilla  is  the  bone  most  frequently  affected,  and  the  involvement  of 
bone  being  only  secondary  and  incidental. 

Actinomycosis  of  the  spine  is  rare,  but  few  cases  having  been  re- 
ported. In  the  cases  seen  by  the  writers  it  has  resembled  Pott's  dis- 
ease very  closely.  In  one  case  the  diagnosis  was  made  from  a  micro- 
scopic examination  of  the  discharge  from  the  sinuses. 

The  treatment  consists  in  the  administration  of  iodide  of 
potassium. 

Echinococcus  cysts  of  the  spine  have  been  observed. 

MYOSITIS   OSSIFICANS. 

This  affection  in  its  symptoms  is  closely  enough  allied  to  those 
caused  by  certain  joint  diseases  to  require  mention.  The  affection 
seems  to  be  roughly  divided  into  2  types :  ( i )  a  multiple  affection  in- 
volving various  parts  of  the  skeleton  spoken  of  as  myositis  ossificans 
progressiva  and  apparently  constitutional;  (2)  a  form  dependent  on 
single  or  repeated  trauma  (traumatica).  The  pathology  is  unsettled 
and  may  be  studied  in  the  references.2  The  characteristic  of  the 
affection  is,  in  the  first  form,  the  occurrence  of  multiple  bony  tumors 
in  connection  with  the  muscles.  Such  cases  begin  generally  in  child- 
hood. The  muscles  are  tender  to  pressure  and  deformities  may  result 
from  the  presence  of  masses  of  bone  in  abnormal  situations.  No 
satisfactory  treatment  of  this  variety  has  been  formulated.  The  trau- 
matic form  results  in  a  persistent  thickening  at  the  site  of  some  injury, 
which  impairs  the  muscle  or  muscles  involved,  and  there  may  be 

1  Whitman:  Pediatrics,  1899,  vii.,  Nos.  4  and  5  (with  bibliography). — Janeway: 
Am.  Jour.  Med.  Sci.,  October,  1903  (with  bibliography). 

2  Bocker :  Zeitsch.  f .  orth.  Chir.,  1908,  xxii.,  1-3. — Jones  and  Morgan :  Archiv 
Rontgen    Ray,   etc.,    1905-6. — Stevens :   Jour.    A.    M.    A.,    1913,   lx.,   203. — Lehman : 
Deut.  z.  f.  Chir.,  1914,  cxxvi.,  213. 


176  ORTHOPEDIC  SURGERY 

found  by  the  .r-ray  even  a  few  days  after  injury  plates  of  bone  in 
intimate  association  with  muscle  tissue.  In  some  instances  this  is 
undoubtedly  merely  periosteum  torn  from  the  bone;  in  other  cases  this 


FIG.   141. — Myositis   Ossificans.      (Michelson.) 


explanation   does   not   hold   and   one    must   assume   the   independent 
formation  of  bone  in  muscular  tissue. 

If  such  formations  do  not  absorb  sufficiently  to  prevent  proper 
function  of  involved  parts  they  should  be  removed  by  operation. 


CHAPTER  IX. 

THE  DEFORMITIES  OF  RICKETS. 

THESE  deformities  result  from  the  inability  of  the  bone  to  sustain 
without  bending  the  weight  or  pressure  or  strain  which  comes  upon  it 
from  muscular  action,  assumed  attitude  or  locomotion. 

These  deformities  follow  a  pathological  condition  existing  in  the 
bones  in  early  childhood  and  in  adolescence. 

Definition. — Rickets  is  a  constitutional  disease  which  affects  young 
children.  In  the  osseous  system  there  is  a  local  or  general  disturbance 
of  the  normal  process  of  ossification,  as  a  result  of  which  the  epiphyses 
become  enlarged  and  the  affected  bones  become  soft  and  plastic; 
growth  is  delayed  and  deformities  of  a  serious  character  may  arise. 
The  affection  itself  does  not  belong  to  the  category  of  surgical  dis- 
eases; but  the  resulting  deformities  demand  strictly  surgical  treat- 
ment. 

Ossification  after  the  rhachitic  process  is  over  may  become  ex- 
cessive, making  the  bone  more  firm  and  dense  than  normal.  Infrac- 
tions or  partial  fractures,  with  the  break  on  the  concave  side  of  the 
long  bones,  may  occur  before  curative  ossification  has  been  estab- 
lished. The  ligaments  become  relaxed  and  stretched  and  the  muscles 
flabby  from  disuse. 

Occurrence  and  Etiology. — Rickets  is  an  affection  occurring  com- 
monly during  the  first  dentition.  Cases  of  rickets,  however,  occur 
during  adolescence  and  a  condition  resembling  rickets  is  at  times  con- 
genital and  has  been  discussed  under  the  heading  of  Chondrodys- 
trophia  Foetalis. 

The  rickets  of  adolescence,  or  late  rickets,  is  a  disease  which  affects 
persons  at  about  the  age  of  puberty.  The  physical  signs  are  the  same 
as  in  the  rickets  of  early  life,  except  that  the  epiphyseal  enlargement 
is  generally  not  so  great.  Boys  and  girls  are  about  equally  affected. 

Causation. — Rickets  is  an  affection  of  faulty  nutrition.  It  is 
much  more  prevalent  among  the  crowded  poor  of  the  cities  than  in 
rural  communities,  and  certain  races  seem  to  be  more  subject  to  the 
affection  than  others.  The  children  of  the  negro,  Italian,  and  Portu- 


1 78 


ORTHOPEDIC  SURGERY 


guese  poor  are  more  frequently  afflicted  than  the  Irish  in  our  Atlantic 
American  cities. 

Changes  in  the  Bones. — Enlargement  of  the  epiphyses  appears, 
especially  at  the  wrists,  ankles,  and  anterior  ends  of  the  ribs.     These 


FIG.   142. — Skeleton   in    Rickets.      (Warren   Museum.) 


enlargements  do  not  involve  the  joints.  At  the  ribs  one  finds  the 
"  rosary,"  a  series  of  bead-like  enlargements  easily  felt  at  the  junc- 
tion of  the  cartilages  and  the  ribs,  and  a  small  degree  of  epiphyseal 
enlargement  is  easily  detected  here,  and  is  not  likely  to  be  mistaken 
for  anything  else.  When  these  changes  have  occurred,  the  bones 


THE  DEFORMITIES  OF  RICKETS 


179 


have  already  softened  and  curvatures  of  the  long  bones  may  have 
begun. 

The  forces  that  work  to  produce  deformity  in  the  softened  bones 
are  muscular  action,  gravity,  pressure  from  weight,  atmospheric  re- 
sistance, and  the  pressure  exerted  on  bony  structures  by  growing 
organs. 

The  typical  head  of  rickets  shows  a  high,  square,  prow-shaped 
forehead,  with  a  decided  prominence  of  the  lateral  parts  of  the  frontal 
bones  (frontal  eminences)  and  sometimes 
the  parietal  eminences  as  well. 

The  anterior  jontanel,  which  should 
normally  close  at  about  the  eighteenth 
month,  remains  widely  open  and  does  not 
ossify  until  perhaps  the  third  year,  or 
even  later.  The  posterior  font  and  some- 
times remains  open  for  months. 

Deformities  of  the  chest  are  among 
the  most  common  produced  by  rickets, 
and  they  occasionally  exist  without  any 
well-marked  signs  of  rickets  elsewhere. 
It  is  not  unusual  to  see  young  girls  about 
the  age  of  puberty  who  have  discovered 
some  inequality  in  the  chest  or  prominence 
of  the  lower  ribs,  perhaps,  but  who  pre- 
sent no  other  signs  of  rickets.  In  these 
cases  it  seems  reasonable  to  assume  that 
a  slight  degree  of  bone  softening  existed 
in  childhood. 

In  a  typical  rhachitic  chest  the 
clavicles  are  shorter  and  more  curved  than 
they  naturally  should  be.  The  chest  is 
narrow  and  prominent  in  front;  it  shows 
the  effect  of  lateral  compression,  and  the  FIG.  i43. -Extreme  Deformity  from 
sternum  projects  so  prominently  that  the 

name  of  pigeon  breast,  or  pectus  carinatum,  is  commonly  given  to  it. 
A  transverse  depression  in  the  chest,  known  as  Harrison's  sulcus,  also 
occurs  in  the  typical  cases,  which  is  most  evident  just  below  the  nipples. 
The  prominence  of  the  abdomen  is  almost  universal  in  well-marked 
rickets.  Rhachitic  children,  as  a  rule,  learn  to  walk  late. 

A  very  common  deformity  of  the  spinal  column  due  to  rickets  is 
a  posterior  bowlike  curve  (involving  the  dorsal  and  lumbar  regions). 


i8o 


ORTHOPEDIC  SURGERY 


It  is  a  uniform  curve  of  a  part  of  the  column,  and  is  most  prominent 
at  the  junction  of  the  dorsal  and  lumbar  regions.  This  attitude 
seems  the  result  of  a  long-continued  seated  position,  with  a  \veakness 
of  the  muscles,  which  fail  to  hold  the  spine  in  the  erect  position.  The 
curve  is  usually  rounded  rather  than  sharp,  and  the  prominence  is 


FIG.  144. — Deformity  of  Spine  in  Rickets. 


not  limited  to  one  vertebral  spinous  process,  as  is  the  case  in  early 
Pott's  disease.  The  rhachitic  curve  of  the  spine  is,  as  a  rule,  flexible 
if  the  child  lies  upon  its  face  and  is  lifted  by  the  legs.  In  the  acuter 
stages  and  after  marked  bone  changes  have  taken  place  marked  stiff- 
ness may  be  seen. 

The  attitude  of  a  child  affected  with  well-marked  rickets  is  char- 
acteristic. It  exists  in  most  marked  cases  of  knock-knee  and  bow- 
legs,  and  sometimes  in  a  less  degree  with  milder  grades  of  the  affec- 
tion. The  child  stands  with  the  legs  apart,  the  thighs  flexed,  and  the 
knees  bent,  the  back  is  arched,  and  the  shoulders  are  thrown  back. 

Deformity  of  the  pck'is  may  be  induced  by  rickets,  the  body 
weight  being  borne  by  a  bony  arch  which  causes  it  to  bend  under 
weight,  and  deformities  may  result,  which  may  be  of  importance  in 
childbirth. 

Except  in  very  severe  cases,  the  ami  bones  are  not  seriously  curved. 


THE  DEFORMITIES  OF  RICKETS 


181 


The  curvatures  follow  no  special  rule,  but  generally  they  are  an  exag- 
geration of  the  normal  curves  of  the  bone.  The  curvature  of  the 
arm  bones  may  be  due  to  creeping,  or  to  lifting  the  child  continually 


FIG.  145.. — Attitude  of  Severe  Rickets, 
Showing  Lordosis  and  Rotation  of 
Pelvis. 


FIG.  146. — Case  of  Osteornalacia  in  a  Girl  of 
Fifteen  Years,  Showing  Deformities  of  Legs 
and  Arms.  (C.  F.  Painter.) 


by  taking  hold  of  the  forearm  in  one  place,  but  often  apparently  is 
the  result  of  muscular  action. 

The  rhachitic  deformities  of  the  legs  are  of  such  importance  that 
they  will  be  considered  separately. 

Flat-foot  is  a  very  common  accompaniment  of  rickets.  The  affec- 
tion is  considered  under  flat-foot. 

In  general,  the  skeleton  is  not  only  deformed  but  stunted,  and 
persons  who  have  rickets  severely  in  childhood  do  not  reach  average 
size  in  adult  life,  as  a  rule.  The  osseous  deformities,  in  most  cases, 
persist  to  a  certain  extent  through  life.  Notably  is  this  true  of  the 
shape  of  the  skull  and  the  chest. 


182  ORTHOPEDIC  SURGERY 

Diagnosis. — The  diagnosis  in  fully  developed  rickets  is  simple;  but 
when  the  affection  is  beginning,  its  recognition  may  be  attended  with 
difficulty. 

In  beginning  rickets,  suggestive  symptoms  are  restlessness  and 
sweating  at  night,  and  universal  tenderness  in  acute  cases.  In  cases 
where  the  disease  is  more  fully  developed  the  diagnostic  points  are,  the 
epiphyseal  enlargement  of  the  ends  of  the  long  bones,  especially  the 
wrists  and  the  sternal  ends  of  the  ribs;  the  prow-shaped  head;  the 
deep,  small  chest ;  the  big  belly ;  delayed  dentition ;  delayed  walking, 
and  an  anterior  fontanel  open  long  beyond  the  proper  time.  If  the 
disease  has  advanced  still  further,  one  often  finds  curvature  of  the 
bones  of  the  legs  and  arms. 

Prognosis. — \Yhen  the  disease  is  left  to  itself  it  generally  runs  its 
course,  and  after  a  decided  degree  of  bony  deformity  has  occurred 
the  process  of  bone  softening  is  spontaneously  arrested,  and  the  bones 
harden  in  their  deformed  condition.  Spontaneous  arrest  of  the  dis- 
ease may  take  place  at  any  stage  without  treatment,  but,  as  a  rule, 
in  severe  cases  not  before  a  serious  degree  of  bony  deformity  has 
been  produced.  \Yhen  the  disease  is  treated  efficiently,  the  prognosis 
as  to  life  is  always  favorable,  and  the  disease  is,  as  a  rule,  easily 
amenable  to  treatment. 

The  kyphosis  above  alluded  to  disappears  or  diminishes  with  the 
growth  of  the  child  under  proper  treatment.  Lateral  curves,  how- 
ever, are  more  permanent. 

Treatment. — The  treatment  of  rickets  consists,  first,  in  the  proper 
feeding  and  hygiene  of  the  child.  Drug  treatment  is  manifestly  sec- 
ondary in  importance  to  careful  regulation  of  the  diet  and  hygiene. 

The  discussion  of  the  operative  and  mechanical  treatment  of  rickets 
will  be  taken  up  under  the  head  of  knock-knee  and  bow-legs. 

KNOCK-KNEE. 

Knock-knee,  or  gcnn  I'alguni.  is  the  name  applied  to  an  internal 
angular  prominence  of  the  knee,  in  which  the  bones  of  the  leg  form 
an  abnormal  lateral  angle  with  the  bones  of  the  thigh,  and  this  angle 
opens  outward. 

Occurrence  and  Etiology.  — The  deformity  is  one  of  common  oc- 
currence, and  about  half  as  common  as  bow-legs.  Both  deformities 
affect  boys  more  often  than  girls. 

Knock-knee  is  a  deformity  which  appears  for  the  most  part  shortly 
after  the  children  learn  to  walk,  but  it  occurs  occasionally  at  the  time 
of  adolescence. 


THE  DEFORMITIES  OF  RICKETS 


183 


Knock-knee  occurring  in  the  first  period  named  is  almost  always 
associated  with  general  rickets,  and  is  sometimes  called  genu  valgum 
rhachiticnm,  to  distinguish  it  from  the  form  occurring  at  puberty, 
which  is  spoken  of  as  genu  valgum  staticum  or  adolescentium. 

Mechanical  Production  of  Knock-knee. — The  chief  cause  of  the 
deformity  seems  to  be  a  static  one,  due  to  the  superimposed  body 
weight,  pressure  from  faulty  position,  and  abnormal  strain,  acting 
upon  soft  bones.  t 

As  the  normally  formed  human  being  in  the  upright  position  stands 
with  a  certain  amount  of  knock-knee,  it  is  evident  that  the  external 
condyle  of  the  femur  and  the  corresponding  facet 
of  the  tibia  transmit  more  body  weight  than  do 
the  corresponding  internal  articular  surfaces. 

Three  bony  deformities  are  likely  to  be  found 
in  cases  of  knock-knee,  viz. : 

(a)  Difference  in  the  size  of  the  condyles  of 
the  femur. 

(b)  Inequality  in  the  articular  facets  of  the 
tibia. 

(c)  Bending  of  the  diaphyses  of  the  bones 
above  or  below  the  joint.     The  first  named  one 
being  the  usual  and  commonest  variety. 

The  patella  lies  farther  outside  than  it  should 
do,  and  the  knees  are  laterally  loose.  The  leg 
is  rotated  outward  on  the  thigh  in  the  more 
marked  cases,  and  this  is  sometimes  so  marked 
that  a  sort  of  compensatory  inversion  of  the  front  of  the  foot  has  been 
acquired  almost  to  the  condition  of  varus  to  aid  in  keeping  balanced, 
while  flat-foot  exists  in  other  cases. 

Symptoms. — Children  and  adults  tire  more  easily  than  they  should 
when  they  have  knock-knee,  and  occasionally  pain  and  sensitiveness 
are  complained  of  over  the  internal  lateral  ligament  of  the  knee;  as 
a  rule  children  with  knock-knee  are  clumsy  and  have  a  poor  sense  of 
balance.  In  the  standing  position  it  is  noticed  that  the  knees  are 
unduly  prominent  on  the  inside  aspect  of  the  leg,  and  that  the  tibiae 
diverge  so  that  the  feet  are  perhaps  only  an  inch  or  so  apart,  or, 
again,  in  severe  cases,  a  considerable  distance.  In  cases  in  which  the 
angular  deformity  is  very  great,  the  patients  find  the  easiest  position 
for  standing  is  with  one  knee  behind  the  other,  so  that  in  this  way 
the  feet  may  be  brought  together  with  one  knee  generally  a  little 
hyperextended. 


FIG.  147. — Axis  of  a  nor- 
mal leg,  and  of  one 
affected  with  Knock- 
knee. 


i84 


ORTHOPEDIC  SURGERY 


The  gait  of  a  patient  with  double  knock-knee  is  a  rolling  one, 
consisting  of  a  series  of  slight  lurches,  which  are,  however,  not 
nearly  so  marked  as  in  bow-legs  or  congenital  dislocation  of  the  hip; 
while  what  is  particularly  noticeable  is  the  outward  throw  of  the  leg 
when  it  is  being  brought  forward.  "  Toeing  in  "  is  common,  especially 


FIG.    148. — Slight   Knock -knee. 


FIG.    149. — Moderate   Knock-knee. 


in  the  slighter  grades,  and  slight  knock-knee  is  the  most  common 
cause  of  the  toeing  in,  noticed  in  young  children. 

The  angular  deformity  disappears  when  the  knee  is  flexed  to  a 
right  angle,  except  in  cases  in  which  the  chief  deformity  is  in  the 
tibia. 

As  the  deformity  is  most  severe  when  the  leg  is  in  the  extended 
position,  all  mechanical  treatment  applied  to  the  correction  of  knock- 


THE  DEFORMITIES  OF  RICKETS 


185 


knee  must  be  to  the  fully  extended  leg.  When  the  leg  is  fully  flexed 
any  inequality  in  the  length  of  the  condyles  is  most  evident,  as  seen 
in  outline  from  the  anterior  surface  of  the  thigh.  This  may  be  regis- 
tered by  shaping  a  lead  strip  to  the  lower  surface  of  the  femur  when 


FIG.   150. — Different  Types  of  Knock-knee. 

the  knee  is  fully  flexed,  and  drawing  an  outline  on  paper  from  the 
lead  strip. 

Occasionally  one  sees  a  combination  of  knock-knee  and  bow-legs  in 
the  same  subject. 

Loose  Knees. — In  young  children  beginning  to  walk,  who  have 
grown  rapidly  or  who  have  perhaps  the  mildest  degree  of  rickets, 
there  is  often  developed  a  laxity  of  the  knee-joint  which  may  require 
treatment.  Such  children  stand  with  the  knees  prominent  inward,  but 
the  deformity  disappears  on  lying  down  and  no  overgrowth  of  the 
internal  condyle  is  to  be  found.  The  knees  can  easily  be  hyper- 


ORTHOPEDIC  SURGERY 


extended  and  are  abnormally  movable  laterally,  and  such  children  are 
unsteady  on  their  feet.  The  treatment  consists  of  the  measures  to  be 
described  in  speaking  of  the  mildest  cases  of  knock-knee. 


FIG.  151. — Severe  Flat-foot  Associated  with  Knock-knee. 

Measurement  of  the  Deformity. — The  simplest  and  most  reliable 
method  of  registration  is  to  have  the  patient  sit  upon  a  sheet  of  brown 
paper  with  the  legs  extended  and  the  feet  pointing  upward ;  and  then, 


THE  DEFORMITIES  OF  RICKETS 


187 


with  a  pencil  held  perpendicularly  to  the  paper,  to  trace  the  outline 
of  the  legs. 

Diagnosis. — The  diagnostic  points  which  mark  the  affection  known 
as  knock-knee  are  an  inward  angular  deformity  at  the  knee,  which 
disappears  on  flexion  of  the  leg  upon  the  thigh.  There  is  also  in  the 


FIG.  152.: — Severe    Knock -knee    due    to    Rick- 
ets.     Seen   from  behind. 


FIG.  15*  — Slight  Knock -knee  Resulting 
from  Tuberculous  Disease  of  the  Left 
Knee.  Now  cured. 


latter  position  to  be  noted  a  relative  prominence  of  the  internal  condyle 
of  the  femur  in  nearly  all  cases.  The  .i'-ray  is  of  use  in  defining  the 
chief  location  of  the  deformity  when  necessary. 

Prognosis. — In  severe  cases  spontaneous  improvement  is  not  to 
be  expected.  Children  with  a  slight  degree  of  knock-knee  which  is  not 
progressive  will  probably  outgrow  it  without  any  treatment  if  in 
vigorous  health.  If  the  deformity  is  moderate  or  severe,  the  chances 


188 


ORTHOPEDIC  SURGERY 


are  strong  that  the  affection  will  remain  stationary,  or  more  probably 
will  become  worse  as  time  goes  on,  unless  active  treatment  is  begun. 

Treatment. — The   treatment   of   knock-knee    falls   into   three   di- 
visions: I.  Expectant.    II.  Mechanical.     III.  Operative. 


FIG.  154. — Bow-leg  of  Right  Leg, 
Knock-knee  and  Flat-foot  on 
Left. 


FIG.    155 Hyperextended    Position    of 

the  Knees,  Frequently  Seen  in  Con- 
nection with  Knock-knee  or  Loose 
Knee. 


I.  The  expectant  method  of  treatment  relies  upon  nature's  efforts 
to  repair  the  deformity ;  efforts  which  are  aided  on  the  part  of  the 
surgeon  by  keeping  the  child  off  of  its  feet  to  a  greater  or  less  extent, 
and  by  constitutional  treatment  and  by  massage  and  corrective  manip- 
ulation. 

\Yhen  the  expectant  method  is  chosen  in  rhachitic  knock-knee,  the 
child  should  at  once  be  put  under  the  best  possible  conditions  as  to 
hygiene  and  diet. 


THE  DEFORMITIES  OF  RICKETS 


189 


The  legs  should  be  rubbed  and  manipulated  each  night,  and  the 
manipulation,  in  cases  of  knock-knee,  should  be  directed  to  the  gentle 


FIG.  156. 


FIG.  157. 


FIG.  158. 


FIG.  159. 


FIGS.    156    and    157.— Knock-knee.      Mechanical 
treatment  for  one  and  one-half  years. 


FIGS.  158  and  159.— Knock-knee  Cured  in 
Three  Years  by  the  Use  of  Simple  Out- 
side Upright.  A  good  average  result. 


correction  of  the  deformity  by  repeated  mild  manual  pressure.    With 
one  hand  the  manipulator  presses  the  knee  outward,  while  with  the 


FIG.  1 60. — Case   of   Knock -knee,    Showing  also   the  Tracings   of   the   Legs  at  an   Interval  of 
Four   Years  with  no  Treatment. 

other  he  presses  the  lower  part  of  the  tibia  inward.    Even  with  a  very 
slight  degree  of  force  a  certain  yielding  can  be  felt  in  the  direction 


190  ORTHOPEDIC  SURGERY 

of  improvement,  and  then  the  pressure  should  be  relaxed  and  the 
limb  allowed  to  resume  its  first  position.  This  manipulation  should 
be  repeated  gently  many  times,  continuing  each  pressure  only  a  few 
seconds. 

Tracings  should  be  regularly  taken  to  determine  whether  the  de- 
formity is  improving  or  is  stationary. 

It  is  advisable  in  early  knock-knee  to  raise  the  inner  border  of 
the  boots  one-quarter  of  an  inch  in  order  to  bring  the  line  of  weight 
bearing  at  the  knee  as  far  outside  as  possible. 

II.  Mechanical  Treatment. — Treatment  by  apparatus  aims  at  the 
gradual  correction  of  the  deformity,  commonly  by  making  counter- 


FIG.   161. — Manipulation   in  the  Treatment  of   Knock-knee. 

pressure  against  the  internal  condyle  to  prevent  the  further  giving  way 
of  the  knee  and  to  pull  it  outward  to  a  fixed  point  furnished  by  an 
outside  upright.  Mechanical  treatment  is  to  be  used  up  to  the  age  of 
4  and  osteotomy  from  4  upward. 

In  the  ambulatory  treatment  of  the  affection,  a  brace  which  has 
been  in  use  for  some  years  at  the  Children's  Hospital  has  proved  itself 
efficient  in  practical  use.  It  is  a  light  steel  rod  attached  below  to  a 
steel  sole  plate  and  jointed  at  the  ankle.  It  runs  up  the  outside  of 
the  leg  as  far  as  the  trochanter,  and  then  the  rod  is  bent  backward 
and  upward,  to  lie  against  the  upper  part  of  the  buttock  and  to  serve 
as  an  arm  by  which  the  legs  can  be  everted  if  the  child  toes  in  in 
walking.  The  knee  is  drawn  upon  by  a  square  leather  pad,  pulling 
from  the  shaft  opposite  the  knee. 

III.  Operative  Treatment. — The  modern  operative  treatment  of 
knock-knee  is  comprised  under  the  simple  operations  of  osteotomy  and 
osteoclasis. 


THE  DEFORMITIES  OF  RICKETS 


191 


Osteotomy. — The  operation  consists  in  the  division  of  part  of  the 
bone  by  the  chisel,  and  the  completion  of  the  procedure  by  fracture  of 
the  partly  divided  bone. 

The  operation  is  performed  as  follows :  The  patient's  leg  is  ren- 
dered aseptic  and  the  patient  lies  on  his  side  with  the  leg  extended,  the 
outer  side  of  the  knee  resting  on  a  sand-bag. 

The  osteotome  is  inserted  as  near  to  the  joint  as  is  practicable  with- 
out injury  to  the  joint.  The  osteotome  is  inserted  on  the  inner  side 


FIG.  162. — Knock-knee,   Irons  Applied. 
Front  view. 


FIG.   163. — Knock-knee,  Irons  Applied. 
Side  view. 


of  the  femur  just  above  the  adductor  tubercle.  The  osteotome,  which 
is  driven  through  the  sound  skin  without  an  incision,  is  at  first  placed 
with  its  blade  parallel  to  the  long  axis  of  the  limb  and  driven  to  the 
bone  by  light  blows  of  the  mallet.  When  the  bone  is  reached  the  blade 
is  turned  so  as  to  be  at  right  angles  to  the  long  axis  of  the  femur, 
and  by  successive  blows  with  the  mallet  the  operator  cuts  nearly 
through  the  whole  thickness  of  the  bone.  The  osteotome  is  likely 
to  become  wedged  very  firmly  unless  the  precaution  is  taken  to  move 


ORTHOPEDIC  SURGERY 


the  handle  laterally  after  each  blow.  In  this  way  alone  can  one  cut 
from  the  front  to  the  back  of  the  bone,  for  driving  the  chisel  straight 
through  in  one  line  accomplishes  but  little.  \Yhen  the  osteotome  has 
disappeared  to  a  depth  indicating  that  three-quarters  of  the  bone  has 
been  divided,  it  should  be  withdrawn  and  an  attempt  made  to  fracture 


FIG.  164. — Line  of  Cutting  in 
Osteotomy  for  Knock-knee.  The 
picture  on  the  left  is  the  ordi- 
nary Macewen  operation.  The 
one  on  the  right  shows  the  re- 
moval of  a  wedge  of  bone  re- 
quired only  in  the  severest  cases. 


FIG.    165. — Proper    Position    for    the    Hand 
and  Osteotome  in  Performing  Osteotomy. 


the  thigh  by  bending.  If  this  cannot  be  done,  the  osteotome  should  cut 
further,  for  the  common  mistake  is  a  failure  to  divide  the  anterior 
and  posterior  borders  of  the  femur. 

\Yhen  the  bone  has  broken,  unnecessary  manipulation  should  be 
avoided,  but  the  limb  should  be  put  in  a  slightly  over-corrected  posi- 
tion, and,  after  an  aseptic  dressing  has  been  applied,  a  plaster-of-Paris 
bandage  should  be  put  on  to  hold  the  leg  in  this  position.  But  little 
pain  follows  the  operation.  Xo  change  of  dressing  is  needed;  the 
plaster  may  be  removed  in  three  or  four  weeks,  another  reapplied,  and 
in  six  weeks  or  more  the  patient  allowed  to  stand  on  the  limbs.  Some- 
times, when  the  deformity  lies  chiefly  in  the  head  of  the  tibia,  the 
operation  of  osteotomy  may  be  performed  there  either  alone  or  in 
connection  with  femoral  osteotomy.  The  removal  of  a  wedge  of  bone 
is  rarely  necessary  from  either  the  femur  or  tibia  in  cases  of  knock- 
knee,  except  in  very  unusual  cases.  However,  the  operation  described 
above  is  the  one  to  be  performed.  Osteoclasis  is  less  suited  to  the 
correction  of  knock-knee,  because  it  lacks  the  precision  of  the  oste- 
otomy, and  where  a  fracture  near  the  joint  is  required  the  definite 
location  of  the  fracture  is  desirable,  which  is  to  be  accomplished  best 
by  the  cutting. 


THE  DEFORMITIES  OF  RICKETS 


193 


BOW-LEGS. 

In  bow-legs  the  legs  are  most  often  bowed  with  convexity  outward. 
This  deformity  is  the  reverse  of  knock-knee,  and  is  termed  genii 
varnm.  It  is  single  or  double,  generally  the  latter,  and  may  excep- 
tionally exist  in  one  leg  when  knock-knee  is  present  in  the  other. 


FIG.   1 66. — Moderate     Knock-knee 
Operation. 


Before 


FIG.  167. — Same  Case  After  Macewen  Oste- 
otomy. 


The  curve  is  most  often  a  gradual  and  uniform  bowing  of  the 
femur  and  tibia,  so  that  with  the  feet  together  the  outline  of  the  legs 
forms  an  oval  which  in  severe  cases  approaches  a  circle.  A  second 
class  of  cases  presents  a  bowing  chiefly  in  the  lower  third  of  the  tibia 
which  is  more  angular  in  character,  and  the  femurs  are  practically 
normal;  a  third  class  presents,  either  alone  or  in  conjunction  with  the 


ORTHOPEDIC  SURGERY 


other  deformities,  a  bowing  forward  of  the  tibia  and  sometimes  of 
the  femur  also. 

Occurrence. — The  anatomical  changes  found  are  those  of  rickets. 
The  bending  of  the  bones  is  in  most  cases,  like  the  other  deformities 


FIG.  168.— Bow-legs.    Curve  Involving 
Whole  Leg. 


FIG.   169. — Anterior   Bow-legs. 


of  rickets,  a  simple  yielding,  without  fracture,  except  in  rare  instances, 
where  infractions  as  spoken  of  may  be  present. 

Causation. — Bow-legs  is  essentially  a  rhachitic  deformity  in  chil- 
dren, and  true  bow-legs  can  occur  only  in  a  child  whose  bones  are  soft 
enough  to  bend  easily.  It  occurs  in  the  first  three  or  four  years  of 
life,  and  ordinarily  in  connection  with  general  rickets;  sometimes, 
however,  other  rhachitic  manifestations  cannot  be  detected. 


THE  DEFORMITIES  OF  RICKETS  195 

Bow-legs  of  a  marked  type  is  seen  in  children  who  are  too  young 
ever  to  have  borne  their  weight  upon  their  legs.  Early  walking,  so 
much  talked  about  as  a  cause  of  bow-legs,  is  not  to  be  accounted  a 
factor  of  any  importance  in  their  production  unless  rickets  in  some 


FIG.   170.. — Bow-legs   Affecting   Chiefly   Bones  of   Lower  Leg. 

degree  is  present.  Why  the  bones  should  bend  outward  as  they  do 
is  a  question  which  is  by  no  means  settled. 

Anterior  curvature  of  the  thigh  and  the  leg  bones  is  manifestly 
the  result  of  body  weight  coming  upon  a  flexed  limb,  conjoined  per- 
haps to  the  action  of  the  most  powerful  muscles  in  the  body  (the  flexor 
muscles  of  the  thigh)  pulling  in  the  same  direction. 

The  child  walks  with  a  distinct  waddle  and  generally  with  the 
feet  wide  apart  and  a  tendency  to  invert  the  toes. 

The  deformity  is  almost  always  more  conspicuous  in  the  standing 
position,  both  because  these  children  stand  with  the  legs  so  far  apart 
to  secure  a  good  balance  and  because  the  knee-joints  generally  yield 


I96  ORTHOPEDIC  SURGERY 

somewhat  in  a  lateral  direction  when  the  body  weight  is  superim- 
posed. 

An  inward  rotation  of  the  lower  part  of  the  tibia  exists  in  bow- 
legs  which  causes  "  toeing  in  "  in  walking,  the  correction  of  which  is 
important  after  operation. 

Diagnosis. — The  condition  of  bow-legs  is  evident  on  inspection. 

It  is  often  difficult  to  determine  how  much  of  the  deformity  lies  in 
the  tibia  and  how  much  in  the  femur.  If  the  legs  are  crossed  until 


FIG.  171.  FIG.  172.  Fie.  173. 

FIGS.  171,  172,  and  173.— Case  of  Bow-legs.     Progress  in  three  years 
under  expectant  treatment. 

the  insides  of  the  knees  are  together  when  the  child  is  in  a  sitting 
position,  it  will  be  seen  whether  the  femurs  include  an  oval  space  be- 
tween them  or  are  parallel  to  each  other. 

Prognosis. — The  prognosis  in  outward  bow-legs  is  favorable  in 
young  children,  in  anterior  bow-legs  less  favorable  under  expectant 
or  mechanical  treatment,  but  in  young  children  rational  mechancial 
treatment  of  ordinary  outward  bowing  offers  almost  sure  relief.  Op- 
erative treatment  can  ameliorate  almost  any  condition  of  deformity 
and  often  entirely  rectify  it.  \Yhen  the  deformity  is  extreme  or  the 
bones  are  eburnated,  it  is  not,  of  course,  likely  that  the  child  will  out- 
grow the  bow-legs. 

Treatment. — The  treatment  of  bow-legs,  like  that  of  knock-knee, 
is  to  be  considered  under  three  heads:  I.  expectant,  II.  mechanical, 
III.  operative. 

I.  The  expectant  treatment  is  suited  to  a  large  percentage  of  cases 
of  the  deformity  in  young  children.  In  general,  when  the  curve  is 
uniform,  involving  femur  and  tibia  alike,  the  chances  are  more  favor- 
able for  spontaneous  cure  than  if  the  deformity  is  localized  in  the 
tibia  and  more  angular.  During  expectant  treatment  the  general 
condition  should  be  most  carefully  attended  to.  The  child  should  be 
encouraged  to  be  off  of  his  feet  as  much  as  possible,  and  the  legs 
should  be  massaged  and  manipulated  each  night,  being  gently  bent 
toward  a  straight  direction. 


THE  DEFORMITIES  OF  RICKETS 


197 


In  all  cases  tracings  should  be  taken  at  least  once  each  month,  and 
if  after  two  or  three  months  no  improvement  is  evident,  mechanical 
treatment  should  be  begun. 

In  the  case  of  babies  the  expectant  plan  of  treatment  is  the  one 
to  be  followed  at  first. 

II.  Mechanical  treatment,  which  is  to  be  pursued  up  to  the  age 
of  four  years,  is  based  upon  the  principle  of  drawing  the  knee  inward 
to  a  rod  which  has  counter-points  for  sustaining  outward  pressure 
at  the  upper  part  of  the  thigh  and  at  the  ankle.     Here,  as  in  knock- 
knee,  traction  from  a  rigid  rod  is  more  definite  and  more  satisfactory 
than   from  an  elastic  one.     The 

form  of  apparatus  used  is  of  little 
consequence  so  long  as  it  answers 
the  indications  and  holds  the  knee 
extended. 

The  apparatus  shown  is  the 
one  generally  in  use  at  the  Chil- 
dren's Hospital  in  Boston,  and  is 
serviceable.  It  consists  of  a  steel 
upright,  which  is  attached  below 
to  the  sole  plate  of  the  shoe.  It 
runs  up  nearly  to  the  origin  of  the 
adductor  muscles,  but  it  must  fall 
a  little  short  of  them  or  it  will  ex- 
coriate the  skin  in  walking.  The 
upright  is  then  bent  forward  and 
upward,  and  curved  to  fit  into  the 
groin  and  come  up  as  far  as  the 
posterior  part  of  the  dorsum  of 
the  ilium.  In  this  way  a  lever  is 
provided  with  which  to  evert  the 
feet  to  any  extent  by  altering  the 
curve  of  these  arms  and  strap- 
ping them  together  behind.  Pads  for  the  outside  of  the  legs  are  made 
of  leather  and  buckled  by  two  or  three  straps  to  the  upright,  opposite 
the  greatest  convexity  of  the  curve. 

Anterior  tibial  curves  are  not  susceptible  of  improvement  or  cure 
by  mechanical  treatment  except  in  slight  cases  in  which  the  bones  are 
soft. 

III.  Operative  Treatment Osteoclasis. — Mechanical  fracture  is 

made  feasible  by  the  use  of  osteoclasts,  of  which  the  one  of  'Rizzoli 


FIG.  174. — Bow-leg.     Brace  Applied. 


198 


ORTHOPEDIC  SURGERY 


is  the  simplest  and  illustrates  the  principle.  There  are  more  modern 
and  more  rapidly  acting  instruments,  which  will  be  found  described 
in  the  treatises  on  Orthopedic  Surgery.  The  instrument  is  applied 
to  the  bared  limb,  the  padded  rings  being  adjusted  as  far  as  is  possible 


FIG.   175. — Bow-legs  of  Moderate   Degree 
Before    Operation. 


Same  Case  After  Osteo- 
clasis. 


from  the  point  at  which  fracture  is  desired,  and  the  breaking  pad 
where  the  fracture  is  to  be  located.  In  placing  the  rings  of  the  osteo- 
clast  on  the  limb,  care  should  be  taken  not  to  put  them  too  near  to  the 
joints  of  the  ankle  or  knee,  as  the  epiphyses  might  be  separated  by 
carelessness.  Pressure  is  increased  until  fracture  of  the  bones  takes 
place.  The  fracture  of  the  bones  is  evidenced  by  a  loud  snap  which 
can  be  heard  anywhere  in  the  room. 

After  the  bone  has  been  broken,  the  osteoclast  should  be  removed, 
the  fragments  placed  with  the  hands  in  a  somewhat  over-corrected 
position,  especial  care  being  taken  to  correct  the  rotation  of  the  tibia. 
Sheet  wadding  is  carefully  placed  around  the  leg,  and  the  limb  fixed 


THE  DEFORMITIES  OF  RICKETS 


199 


in  a  plaster  bandage.  The  bandage  should  reach  from  the  toes  to 
the  hip,  and  the  limb  should  be  held  in  the  corrected  position  until 
the  plaster  has  hardened  thoroughly.  Experience  has  shown  that 
the  procedure  is  ordinarily  free  from  risk,  and  in  properly  selected 
cases  the  danger  of  non-union  after  fracture  may  be  disregarded. 
The  limb  should  remain  in  a  fixed  bandage  for  six  weeks  or  more, 
and  no  appliance  is  needed  as  an  after-treatment. 

The  amount  of  force  required  for  the  fracture  of  an  adult  bone 


FIG.  177. — Method  of  Applying  Osteoclast. 


is  very  great,  so  much  so  as  to  make  osteotomy  in  most  instances  a 
preferable  procedure. 

Cases  should  not  as  a  rule  be  operated  upon  until  the  rhachitic 
process  has  been  arrested,  or  recurrence  of  the  deformity  may  take 
place. 

Osteotomy  should  be  employed  in  place  of  osteoclasis  in  cases  of 
bow-legs  ( i )  when  the  curvature  is  so  near  the  joint  that  osteoclasis 
is  not  practicable;  (2)  when  the  bone  is  so  strong  that  osteoclasis 
is  not  desirable  on  account  of  the  contusing  of  the  soft  parts;  (3) 
when  several  curves  exist  in  the  same  leg;  (4)  sometimes  when  the 
curvature  is  anterior;  (5)  in  cases  of  bow-leg  in  which  the  distortion 
is  largely  in  the  lower  epiphysis  of  the  femur;  (6)  in  cases  in  which 
it  is  desired  to  locate  the  fracture  very  accurately,  as  in  badly  united 
fractures  of  both  bones  of  the  leg  with  displacement. 

Osteotomy  for  bow-legs  is  a  similar  operation  to  that  for  knock- 
knee  ;  the  division  of  bone  is  made  wherever  it  appears  most  necessary. 


200  ORTHOPEDIC  SURGERY 

In  young  children  the  fibula  need  not  be  cut  with  the  osteotome,  but 
can  be  broken  manually. 

Anterior  Boic-Lcys. — In  the  treatment  of  anterior  bow-legs,  i.e., 
where  the  curve  is  forward  and  not  to  the  side,  the  tibia  may  be 
broken  by  the  osteoclast  applied  in  the  usual  way,  and  after  the 
fracture  has  been  loosened  by  the  hands  the  leg  may  be  set  straight. 
Tenotomy  of  the  tendo  Achillis  aids  this  attempt  and  is  often  neces- 
sary. Osteotomy,  however,  as  a  rule,  is  more  satisfactory  in  these 
cases.  In  anteriorly  curved  bow-leg  in  children,  a  linear  osteotomy 
can  be  employed  dividing  the  posterior  two-thirds  of  the  tibia  and 
using  the  anterior  portion  as  a  hinge  with  the  interlacing  broken 
fibres  and  uninjured  periosteum  to  promote  healing.  The  osteotome 
is  inserted  in  the  side  of  the  tibia.  By  this  procedure  the  shortening 
caused  by  removing  a  wedge  is  avoided.  Considerable  manipulation 
is  necessary  after  the  osteotomy  to  free  the  fragments  from  the 
shortened  posterior  tissue,  which  is  necessary  to  give  a  corrected 
position.  In  older  cases  a  wedge-shaped  incision  may  be  necessary. 

Cases  will  be  met  where  several  curves  are  present,  and  the  judg- 
ment of  the  surgeon  will  be  exercised  in  a  choice  of  wrhat  bone  is  to 
be  attacked  and  if  more  than  one  shall  be  operated  upon  at  one  time. 
The  surgeon's  purpose  should  be  to  correct  those  deformities  which 
most  interfere  with  normal  gait,  and  leave  others  to  the  correction 
of  growth  or  to  a  second  operation. 

RHACHITIC  CURVES  IN  THE  UPPER  EXTREMITY. 

These  rarely  present  themselves  for  treatment,  and  but  little  fur- 
ther need  be  said  except  that  by  means  of  osteotomy  the  curves  of  the 
upper  extremity  can  be  treated  as  readily  as  those  of  the  lower. 

The  methods  described  can  be  applied  in  the  correction  of  improp- 
erly united  fractures  of  the  upper  and  lower  extremities.  The  prin- 
ciples of  treatment  for  the  correction  of  these  curves,  in  the  main,  are 
those  considered  in  the  treatment  of  rhachitic  curves. 


Y  GF 


COLLEGE  OF 
PHYSICIANS 


CHAPTER  X. 
COXA  VARA. 

THE  name  coxa  vara  is  applied  to  a  condition  in  which  the  neck 
of  the   femur  becomes  more  horizontal  than  the  normal  angle  of 


FIG.   178. — Specimen  of  Coxa  Vara,  no  Clinical  History.      (Warren  Museum.) 

I2O°-I4O°,  which  it  makes  with  the  shaft.     This  bending  of  the  neck 
may  reach  in  extreme  cases  an  angle  less  than  90°. 

Etiology. — The  affection  is  rarely  congenital,  but  more  often  ac- 
quired, and  in  its  purest  form  appears  in  adolescents  as  an  affection 
apparently  primary,  being  called  in  this  case  "  static  "  coxa  vara.  In 
such  cases  one  must  assume  a  diminished  resistance  of  the  bone,  but 
evidences  of  general  rickets  may  be  absent.  The  deformity  also 


201 


202  ORTHOPEDIC  SURGERY 

occurs  in  connection  with  general  rickets  in  children,  in  osteomalacia, 
and  after  destructive  diseases  of  bone,  such  as  tuberculosis,  osteo- 
myelitis, arthritis  deformans,  ostitis  fibrosa,  etc.  It  also  arises  after 
fracture  of  the  neck  of  the  femur  in  adults  and  children  and  after 


FIG.   179. — Specimen    of    Severe    Double    Coxa    Yara    from    an    Adult    Female    (No.    3821    in    the 
Vienna    Pathological   Anatomical   Museum).      (Albert.) 

epiphyseal  displacements  in  children,  in  the  latter  instances  being 
called  "  traumatic  "  coxa  vara. 

The  affection  may  be  unilateral  or  bilateral,  and  affects  males 
more  often  than  females. 

The  neck  of  the  femur  not  only  yields  downward,  but  is  apt 
also  to  rotate  on  the  long  axis  of  the  femur.  The  most  common 
twist  of  this  sort  is  backward,  which  causes  eversion  of  the  foot  and 
leg,  although  inversion  of  the  foot  and  leg  is  sometimes  present  from 
the  reverse  twist.  There  may,  however,  be  a  simple  downward  dis- 
placement without  any  appreciable  twist.  Exceptionally  there  may 


COXA  VARA 


203 


be  bending  outward  of  the  upper  part  of  the  femur,  which  gives 
rise  to  a  deformity  similar  to  that  caused  by  the  bending  of  the  neck 
of  the  femur. 


FIG.  180. — Coxa  Vara  and  Bending  Outward  of  the  Upper  Shaft  of  the  Femur.      (Albert.) 

In  traumatic  co.ra  rara  a  fall  in  a  child  may  be  followed  by  a  tem- 
porary lameness  in  one  hip,  which  later  shows  the  signs  described 
above,  or  such  a  fall  is  followed  immediately  by  pain,  shortening, 


204  ORTHOPEDIC  SURGERY 

eversion,  and  limited  abduction  of  varying  degree.  An  .r-ray  shows 
either  an  epiphyseal  displacement  or  an  impacted  fracture  or  infraction 
of  the  neck  of  the  femur.  Such  cases  are  frequently  unrecognized 
until  marked  changes  in  the  neck  of  the  femur  have  taken  place. 
Again,  after  recovery  from  a  fracture  of  the  femoral  neck,  walking 
may  be  begun  before  complete  consolidation  has  taken  place,  and  a 
yielding  of  the  neck  of  the  femur  may  occur  later. 

Symptoms. — The  symptoms  of  coxa  vara  are  discomfort  and  irri- 


FIG.   181. — Sagittal  Section  of  Coxa  Vara,   Showing  Rearrangement  of  Trabeculae  to  Compensate 

for  Cross  Strain.      (Abbott.) 

tability  in  the  affected  joint  on  walking  with  characteristic  limitation 
of  motion  in  abduction  due  to  the  altered  relation  of  the  trochanter 
and  head  of  the  femur,  the  trochanter  impinging  on  the  pelvis  in 
abduction.  In  periods  of  joint  irritation  this  limitation  may  extend 
to  other  joint  motions.  Lameness  is  present,  and  in  bilateral  cases 
the  gait  becomes  a  waddling,  restricted  gait. 

Shortening  of  the  affected  limb  is  present,  with  generally  some 
muscular  atrophy ;  the  trochanter  is  found  above  Nelaton's  line  and 
unduly  prominent,  and  flexion  of  the  thigh  is  generally  made  in  an 


COXA  VARA 


205 


abducted  plane.  In  severe  double  cases  the  thighs  may  be  crossed 
on  the  abdomen  in  extreme  flexion.  The  .r-ray  shows  a  diminished 
angle  of  the  neck  of  the  femur  with  the  shaft. 

Diagnosis. — The  recognition  of  coxa  vara  is  not  always  easy. 
The  signs  on  which  reliance  must  be  placed  are  shortening,  elevation 
of  the  trochanter,  limited  abduction, 
and  prominence  of  the  trochanter. 
If  the  child  stands  on  the  affected  leg 
the  buttock  of  the  well  side  will  not 
drop  (Trendelenberg's  sign),  which 
is  the  case  in  congenital  dislocation 
of  the  hip.  An  a*-ray  is  of  assistance 
in  establishing  the  changed  relation 
between  the  neck  and  shaft  of  the 
femur. 

The  condition  most  likely  to  be 
confused  with  coxa  vara  is  hip  dis- 
ease, but  in  the  former,  generally  ab- 
duction is  the  only  motion  limited 
and  joint  restriction  is  rarely  ex- 
treme; shortening  is  present  to  a  de- 
gree which  would  only  exist  with 
much  destruction  of  bone  in  tuber- 
culosis, and  the  .r-ray  is  of  much 
value. 

In  young  children  it  is  sometimes 
difficult  to  discriminate  between  this 
condition  and  congenital  dislocation 
of  the  hip.  In  both  the  trochanter 
is  prominent,  and  above  Nelaton's 
line,  shortening  is  marked  and  limi- 
tation of  joint  motion  comparatively 
slight.  In  dislocation  the  head  of  the  bone  can  generally  be  felt  under 
the  fingers,  but  in  some  cases  this  is  not  easy  to  detect,  and  the 
^•-ray  will  have  to  be  resorted  to  when  available  to  satisfactorily  estab- 
lish the  diagnosis. 

Diagnosis. — The  diagnosis  is  generally  to  be  made  by  the  signs 
given  above,  aided  by  the  .r-ray,  and  the  conditions  most  likely  to  be 
confused  with  coxa  vara  are  congenital  dislocation  of  the  hip  and 
hip  disease. 

Prognosis. — In  the  coxa  vara  of  young  children  accompanying 


FIG.  182. — Traumatic  Coxa  Vara  of 
Right  Leg,  from  an  Accident  Occur- 
ring when  Patient  was  Four  Years 
Old.  (Hoffa.) 


2O6 


ORTHOPEDIC  SURGERY 


general  rickets,  it  seems  likely  that  the  deformity  is  in  many  cases 
at  least  outgrown  from  the  rarity  of  severe  coxa  vara  in  adults,  who 
have  had  rickets  in  childhood.  In  other  cases  there  seems  no  reason 
to  look  for  spontaneous  cure. 

Treatment. — The  treatment  of  coxa  vara  is  to  be  classed  as  con- 
servative or  operative. 

Conservative   Treatment. — In  the  stage  when  the  bone  may  be 
regarded   as   congested  and   therefore   unfit   to   bear  weight-bearing 

strain,  crutches,  or  some  apparatus 
forming  a  perineal  crutch  (the 
Thomas  knee-splint  and  the  conva- 
lescent hip-splint)  may  be  used. 
With  restricted  walking  and  stand- 
ing, such  treatment  may  be  regarded 
as  likely  to  quiet  joint  irritation  and 
as  a  check  to  the  increase  of  the  de- 
formity. If  sufficiently  long  con- 
tinued it  should  influence  growth 
toward  the  normal.  Massage  is  a 
useful  addition  to  such  treatment  in 
stimulating  the  local  circulation. 
Traction  in  bed  in  an  abducted  posi- 
tion is  desirable  in  acutely  irritated 
cases. 

Operative  Treatment. — If  con- 
servative treatment  has  failed  to  give 
relief,  or  if  the  case  is  already  well 
marked,  some  more  active  treatment 
is  desirable.  If  there  is  reason  to 
suppose,  from  the  history,  the  symp- 
toms, and  the  .i--ray,  that  the  bone 
of  the  femoral  neck  is  still  soft,  the 
patient  should  be  anaesthetized,  and 
the  leg  forcibly  abducted  with  the 
idea  of  bending  the  neck.  It  is  not 
desirable  to  produce  a  loose  frac- 
ture. Following  this  the  leg  is  fixed  in  an  abducted  position  by  a  plas- 
ter-of-Paris  spica  for  two  months,  after  which  protected  use  (by  means 
of  a  perineal  crutch)  may  be  begun. 

Osteotomy. — In  cases  where  there  is  no  reason  to  suppose  that 
the  bone  is  still  soft  enough  to  bend,  and  where  operative  correction 


FIG.  183. — Fracture  of  Ilip  Four  Years 
after  the  Accident.  Shows  Eversion. 
(Whitman.) 


COXA  VARA 


207 


seems  advisable,  osteotomy  of  the  neck  or  shaft  of  the  femur  affords 
the  best  means  of  relief. 

The   method   generally  advisable   is  to   divide   the   shaft  of  the 
femur  transversely   below   the   trochanter   minor  by   an   osteotome, 


FIG.  184. — X-Ray  Illustrating  Condition  of  the  Neck  of  the  Femur  After  Operation  for  Coxa  Vara. 


and  after  correction  of  the  rotation  of  the  femur  to  abduct  the  leg 
and  fix  it  in  a  position  of  marked  abduction  in  a  plaster-of-Paris  spica. 
A  wedge-shaped  osteotomy  at  the  same  level  may  be  performed 
in  cases  where  no  rotation  of  the  leg  exists,  and  has  the  advantage  of 
leaving  a  hinge  of  bone  at  the  inner  surface  of  the  femur  so  that  no 
slipping  by  of  the  fragments  will  occur;  but  it  is  generally  more  dif- 
ficult to  perform  than  a  linear  osteotomy,  in  addition  to  which  it 
increases  shortening. 


208  ORTHOPEDIC  SURGERY 

An  osteotomy  of  the  femoral  neck  through  an  anterior  incision 
attacks  more  directly  the  seat  of  the  deformity,  but  this  operation 
requires  a  rather  deep  incision;  drainage  of  the  wound  is  poor,  and 
the  method  offers  in  most  cases  no  marked  advantage  over  the  one 
advocated. 

Traumatic  Coxa  Vara. — In  cases  seen  long  after  the  accident  the 
treatment  is  the  same  as  that  described  above.  In  recent  cases  force 


FIG.  185.— Radiograph  of  a  Severe  Rhachitic  Coxa  Vara  in  a  Patient  Seven  Years  Old. 

should  be  used  to  correct  the  diminished  angle  of  the  neck  and  the 
limb  fixed  in  abduction.  Unprotected  use  of  such  a  leg  should  not 
be  allowed  for  many  months  after  the  correction. 

COXA  VALGA. 

Coxa  Yalga  1  is  the  name  applied  to  the  condition  which  is  the  re- 
verse of  coxa  vara,  and  which  has  been  extensively  studied  in  the  last 
1  Drehmann :  Zeitsch.  f.  orth.  Chir.,  xvi.,  1-2. 


COXA  VARA 


209 


few  years.  In  this  the  angle  between  the  neck  and  the  shaft  of  the 
femur  is  increased  above  140°.  In  connection  with  this  deformity 
also  twists  of  the  neck  of  the  femur  may  occur. 

The  causes  of  the  deformity  are  as  follows :  trauma  probably 
resulting  in  defective  epiphyseal  growth,  osteomalacia,  rickets,  osteo- 
myelitis of  the  pelvis,  infantile  paralysis,  and  amputation  of  the  leg 


FIG.  186.— Radiograph  of  a  Sagittal  Section  of  a  Specimen  of  Coxa  Valga,  Amputation  of  the  Thigh 
having  been  Done  in  Childhood.     (Turner.) 


causing  disuse,  multiple  exostoses,  genu  valgum,  and  congenital  dis- 
location of  the  hip.  Congenital  cases  have  been  described,1  and  some 
cases  arise  in  which  no  cause  can  be  assigned. 

The  symptoms  are  pain  and  irritability  of  the  affected  hip, 
with  a  limp  caused  largely  by  the  abducted  and  lengthened 
leg  on  the  side  affected.  The  leg  is  generally  rotated  outward, 
is  longer  than  the  other,  and  is  carried  in  a  position  of 
abduction.  The  trochanter  is  less  prominent  than  normal  and 
is  generally  below  Nelaton's  line;  abduction  is  free  and  adduction 


zzi:  Am.  Journ.  of  Orth.  Surg.,  iv.,  240.  —  Young:  Am.  Journ.  of  Orth. 
Surg.,  iv,  256.  —  Mauclaire  and  Ollivier  :  Arch.  gen.  de  Chir.,  1908,  i.,  I. 


2IO 


ORTHOPEDIC  SURGERY 


restricted    at    the    hip-joint.     The    diagnosis    is    greatly   aided   by   a 
skiagram. 

The  affection   has  been   too   recently   recognized  and   studied  to 
enable    one    to    speak    definitely    as    to    the    treatment    yielding    the 


FIG.   187. — Radiograph  of   Case  of   Coxa   Yalga    Due  to   Infantile   Paralysis. 

best  end  results.  Excellent  immediate  results  have  been  reported 
from  each  of  the  following  methods  of  treatment :  ( i )  Exercises 
and  massage1;  (2)  forcible  adduction  and  retention  in  plaster- 
of-Paris  in  a  position  of  extreme  adduction2;  (3)  osteotomy 
of  the  neck  of  the  femur  and  allowing  the  shaft  to  slip  upward 

1  Stieda:  Arch.  f.  klin.  Chir.,  87,  I,  243. 

2  Kumaris  :   Arch.  f.  klin.  Chir.,  1908,  87,  3,  625. 


COXA  VARA  211 

on    the    neck    by    diminishing    traction    in    the    after-treatment * ; 


FIG.   188. — Radiograph  of  a  Case  of  Coxa  Valga.      (David.) 

(4)  subtrochanteric  linear  osteotomy2;  subtrochanteric  wedge-shaped 
osteotomy.3 

1  Galeazzi :  loc.  cit. 

2  Allison :  Am.  Journ.  of  Orth.  Surg.,  v.,  228. 
*  Tubby:  British  Med.  Journ.,  1908,  2482. 


CHAPTER  XL 

LATERAL  CURVATURE  OF  THE  SPINE. 

DEFINITION. 

BY  this  term  is  understood  a  constant  deviation  of  the  spinal  col- 
umn, or  a  portion  of  it,  to  either  side  of  the  median  line  of  the  body, 
with  a  resulting  distortion  of  the  trunk.  The  affection  is  also  called 
scoliosis. 

Lateral  curvature  is  either  congenital  or  acquired. 

FREQUENCY. 

The  affection  is  a  common  one,  but  its  prevalence  can  only  be  esti- 
mated, as  statistics  gathered  vary  apparently  according  to  the  standard 
of  the  observer;  but  it  is  probable  that  lateral  curves  of  a  grade  need- 
ing treatment  will  be  found  in  from  20  to  30  per  cent  of  our  school 
children. 

The  distortion  is  seen  more  frequently  in  girls  than  in  boys,  but 
statistics  as  to  the  comparative  frequency  of  the  deformity  in  females 
as  compared  with  males  vary. 

Age. — Although  it  is  probable  that  the  distortion  exists  to  a  slight 
extent  at  an  earlier  age,  the  majority  of  cases  brought  to  the  surgeon 
for  treatment  are  from  ten  to  sixteen  years  of  age. 

PATHOLOGY. 

The  pathological  changes  in  acquired  lateral  curvature  are  not 
those  resulting  from  destructive  disease  of  the  vertebne,  but  are  the 
alterations  of  bone  induced  by  abnormal  pressure  and  strain. 

The  spinal  column,  as  a  whole,  is  bent  and  twisted,  and  the 
individual  vertebne  are  in  places  altered  in  shape  as  well  as  mis- 
placed from  their  normal  relation  to  the  vertical  plane  of  the  trunk. 
The  ribs  and  pelvis  may  be  altered  in  shape.  The  muscles  and  liga- 
ments are  altered  in  their  tonicity  and  length,  and  internal  organs 
may  be  displaced. 

Characteristic  of  the  deformity  is  the  combination  of  a  side  curve 
of  the  spinal  column  with  a  twist,  the  spinous  processes  pointing 

212 


LATERAL  CURVATURE  OF  THE  SPINE  213 

away  from  and  the  vertebral  bodies  being  turned  toward  the  con- 
vexity of  the  curve.  This  rotation  is  the  result  of  the  structure  of 
the  spinal  column,  which  cannot  bend  to  the  side  without  twisting. 

The  changes  seen  necessarily  vary  according  to  the  stage  of  the 
affection  and  the  degree  to  which  the  deformity  has  developed. 

In  the  earliest  stage  of  scoliosis  slight  if  any  anatomical  change 
will  be  found  in  the  bones,  ligaments,  or  muscles;  but  in  the  later 
phases  of  the  affection,  marked  distortion  of  the  whole  spinal  column, 
as  well  as  the  individual  vertebrae,  is  to  be  observed. 

Wherever  a  side  curve  with  rotation  of  the  spine  has  taken  place, 
the  bodies  are  crowded  together  on  the  concave  and  separated  on  the 
convex  side  of  the  curve,  and  the  vertebral  bodies  become  thicker  on 
one  side  than  the  other,  and  changes  in  shape  of  the  articulating  and 
transverse  processes  and  intervertebral  disks  also  take  place.  The 
ribs  follow  the  transverse  processes,  and  show  a  characteristic  pro- 
jection on  one  side  and  flattening  on  the  other.  The  projection  of 
the  ribs  is  naturally  more  noticeable  than  the  projection  of  the  trans- 
verse processes  without  ribs,  so  that  in  the  lumbar  region  the  rotation 
seems  slight  when  compared  with  that  of  the  dorsal  region. 

If  the  column  is  curved  laterally  in  two  or  three  directions,  rota- 
tion necessarily  takes  place  in  different  parts  of  it  in  opposite  direc- 
tions. 

The  intervertebral  cartilages  necessarily  twist  with  the  vertebrae 
and  are  compressed  on  one  side  more  than  on  the  other  in  cases  of 
marked  curves ;  in  severe  cases  they  will  be  found  on  measurement 
thicker  on  the  side  of  convexity  than  of  concavity,  so  that  instead  of 
being  flat  they  are  wedge-shaped  from  side  to  side.  In  some  cases 
the  rotation  is  more  marked  than  the  curve,  the  line  of  the  spines  being 
nearly  straight,  while  the  bodies  are  found  badly  out  of  line,  the  axis 
of  rotation  being  near  the  spines. 

The  ribs  project  backward  at  the  angle  on  the  side  of  the  con- 
vexity of  the  curve  and  forward  on  the  side  of  the  concavity,  and  the 
contour  of  the  thorax  is  changed  from  the  altered  shape  of  the  ribs. 
Cross  sections  of  the  thorax  shows  an  alteration  of  the  diagonal 
axes  of  the  chest,  and  the  section  on  the  convex  side  is  smaller  than 
that  on  the  concave  side,  owing  to  the  flattening  of  the  ribs.  The 
vertebral  bodies  are  also  crowded  into  this  half  of  the  thorax,  so 
that  there  is  less  room  for  expansion  of  the  lung  on  that  side  than  on 
the  other  side.  In  the  severest  cases  of  distortion,  the  lower  ribs  on 
one  side  may  rest  upon  the  crest  of  the  ilium  or  sink  into  the  pelvic 
cavity. 


214 


ORTHOPEDIC  SURGERY 


The  muscles  of  the  spinal  column  in  an  early  case  of  lateral  curva- 
ture are  unaffected,  except  in  cases  of  a  purely  paralytic  nature;  but 
in  advanced  cases  the  muscles  are  degenerated. 

In  advanced  cases  of  lateral  curvature,  the  ligaments  on  the  con- 


FIG.   189. — Transverse  Section  of  a  Scoliotic  Thorax.      (Albert.) 

cave  side  of  the  spinal  column  are  shortened  and  those  on  the  convex 
side  are  elongated.  This  is  the  result  of  adaptive  shortening,  and  is 
not  found  in  the  early  stages  of  the  affection. 

The  pelvis  is  not  necessarily  distorted  in  lateral  curvature  of  the 
spine,  but  the  bones  of  the  pelvis  may,  if  not  sufficiently  unyielding  in 
their  structure,  become  altered  by  abnormal  pressure  or  strain.  The 


FIG.  Jyu. — Method  Used  for  Producing  Deformity  of 
Head  by  Flat-Head  Indians.  (From  Sketch  from 
Lewis  and  Clark.) 


FIG.  191. — The  Flat- 
Head  Indian.  An 
old  man. 


pelvis  may  assume  the  appearance  of  obliquity  from  a  prominence 
of  one  hip  due  to  the  uncovering  of  the  crest  of  the  ilium  by  the  over- 
projecting  ribs,  but  true  obliquity  is  exceptional.  \Yhen  there  is 
irregularity  in  the  length  of  the  legs,  obliquity  of  the  pelvis  necessarily 
exists.  The  spinal  cord  is  not  affected  by  lateral  curvature.  The 
spinal  nerves,  in  consequence  of  the  large  size  of  the  foramina,  are 


LATERAL  CURVATURE  OF  THE  SPINE 


215 


not  liable  to  suffer  compression,  but  symptoms  of  nerve-root  pressure 
are  at  times  observed  in  advanced  cases. 

The  abdominal  viscera  are  less  likely  to  be  displaced  than  the 
thoracic  organs,  though  the  liver  may  be  out  of  place  and  altered 
in  form,  the  spleen  may  suffer  some  compression,  and  the  aorta  is 
necessarily  displaced,  but  to  a  less  degree  than  in  Pott's  disease.  The 
lung  on  the  convex  side  of  the  curve  is  much  more  compressed  and 
flattened  than  on  the  other  and  the  heart  is  generally  found  displaced 
toward  the  concavity  of  the  curve  in  severe  cases. 

It  is  known  that  bone,  like  other  portions  of  the  human  frame, 
muscle,  and  skin,  adapts  itself  to  conditions,  being  changed  in  shape 

and  strength  under  pressure  and 
strain,  as  is  shown  by  the  Flat- 
headed  Indians,  whose  skulls  were 
distorted  by  pressure  mechanically 
applied  for  a  long  period  in  infancy. 
The  foot  of  a  Chinese  lady  is  an- 
other illustration. 

ETIOLOGY. 

The  phenomena  of  lateral  curva- 
ture, curve  and  rotation,  have  been 
produced  experimentally  on  the 
cadaver  of  infants,  and  in  animals 
by  securing  for  six  months  the  spine 
of  growing  dogs  by  a  stiff  bandage 
in  a  bent  position.  Growing  chil- 
dren, obliged  to  retain  an  abnormal 
position  through  paralysis,  often  ac- 
quire scoliosis,  and  the  Siamese 
twins,  prevented  from  normal  atti- 
tudes, developed  lateral  curves. 

To  explain  the  development  of 
scoliosis  it  is  only  necessary  to  as- 
sume the  existence  of  a  constantly  applied  force  exerted  upon  the 
spinal  column  in  abnormal  directions.  As  the  resistance  offered  by 
the  bone  differs  in  different  portions  of  the  spine,  and,  as  individuals 
differ,  similar  distorting  conditions  do  not  produce  the  same  deformity 
in  different  individuals.  Of  the  factors  favoring  abnormal  distribu- 
tion of  superimposed  weight,  the  following  may  be  mentioned  as 
being  the  most  common  : 


FIG.  192. — Front  View  of  Lateral  Curva- 
ture, Showing  Prominence  of  Left 
Mamma  in  Right  Dorsal  Convex  Curva- 
ture. 


2l6 


ORTHOPEDIC  SURGERY 


1.  Faulty  attitudes  in  standing  or  sitting. 

2.  Inequality  of  the  length  of  the  limbs,  pelvic  asymmetry,  or  other 
causes  tilting  or  twisting  the  pelvis. 

3.  Abnormal  attitudes  due  to  occupation,  to  defective  eyesight  or 
hearing,  to  torticollis,  muscular  weakness,  or  paralysis. 

4.  To  contractions  following  empyema. 

5.  Congenital  defects,  absence  or  defects  of  the  ribs  or  vertebrae. 
The  primary  curve  may  be  followed  by  secondary  distortions  due 

to  abnormal  muscular  pull  of  the  thoracic  and  abdominal  muscles  upon 


FIG.    193. — Right    Lateral    Curvature.       (Weigel.) 

the  ribs  and  vertebral  column  in  the  patient's  attempt  to  establish 
proper  poise.  These  distortions  vary  according  to  the  variations  in 
abnormal  strains  and  the  abnormality  in  tissue  resistance  at  different 
thoracic  levels. 

Lateral  curvature  is  naturally  favored  by  causes  which  will  dimin- 
ish the  resistance  of  bone  to  abnormally  applied  weight.    Apart  from 


LATERAL  CURVATURE  OF  THE  SPINE 


217 


disease  of  the  structure  of  bone,  these  are:  (i)  rickets  and^osteo- 
malacia;  (2)  abnormal  lack  of  bone  resistance  of  the  spinal  column, 
from  rapid,  excessive,  or  ill-nurtured  growth. 


SYMPTOMS. 


Early  History. — The  deformity  of  scoliosis  is  developed  during  the 
growing  years,  becoming  arrested,  as  a  rule,  at  the  end  of  the  period 
of  growth. 

The  affection  is  ordinarily  discovered  by  the  patient's  mother  at 
the  age  just  previous  to  puberty,  although  it  is  developed  earlier  than 


FIG.   194. — Severe  Lateral  Curvature  (Un- 
treated). 


FIG.    195. — Right    Dorsal,     Slight    Left    Lumbar 
Curve. 


this  in  a  majority  of  cases  without  being  recognized,  except  in  the 
severe  cases.  The  patient  suffers  no  inconvenience  in  this  early  stage, 
and  as  the  child  is  at  an  age  (five  to  ten)  when  the  figure  is  not  care- 
fully scrutinized,  little  attention  is  paid  to  the  slight  elevation  of  the 
shoulder  or  projection  of  the  hip.  Upon  superficial  examination 
but  little  else  is  to  be  seen,  and  these  symptoms  disappear  on  recum- 


218 


ORTHOPEDIC  SURGERY 


bency  or  suspension.  A  careful  examination  often  discloses  a  curve 
of  the  spine  to  the  side. 

In  a  majority  of  cases,  however,  when  the  surgeon  is  consulted, 
well  marked  development  of  the  distortion  has  already  taken  place. 

The  muscular  system  may  or  may  not  be  well  developed,  but  in 


FIG.  196  — Lateral  Curvature 
due  to  Infantile  Paralysis  of 
Muscles  of  Trunk. 


FIG.  197. — Severe  Right  Dorsal,  Left  Lumbar  Curve 
Showing  Marked  Lumbar   Rotation  on  the  Left. 


a  majority  of  cases  the  muscles  are  not  large  or  strong.  In  a  few 
instances  of  growing  girls  with  marked  impairment  of  strength  some 
thoracic  pain  may  be  felt,  and  fatigue  on  exertion  in  walking  or 
standing.  But  cases  of  severe  curvatures  will  be  seen  in  which  devel- 
opment has  slowly  continued  during  the  years  of  younger  adult  life. 
In  the  severe  cases  seen  in  early  or  middle  childhood  the  deformity 


LATERAL  CURVATURE  OF  THE  SPINE 


219 


will  generally  prove  to  be  due  to  congenital  defects,  rickets,  empyema, 

or  infantile  paralysis. 

Spontaneous  arrest  when  adult  life  is  reached  takes  place  in  a 

very  large  number  of  the  slighter  cases,  without  further  development 

of  the  deformity.  Even  in 
many  of  the  severer  types  of 
the  deformity,  patients  will  be 
observed  who  apparently  go 
through  adult  life  without  in- 
crease of  the  deformity. 

Pain. — Painful  symptoms 
are  not  common  in  the  affec- 
tion, but  when  present,  such 
symptoms  may  be  classed  as 
follows : 

1.  Those  due  directly  to  the 
altered    muscular    or   ligamen- 
tous  strain. 

2.  Those  clue  to  the  abnor- 
mal   pressure    from    distorted 
ribs  upon  the  nerves  or  ilium, 
or  by  vertebra  upon  nerves,  or 
to   alteration   of  the   size   and 
shape  of  the  thorax,  and  dis- 
placement of  viscera. 

3.  Neurasthenic    symptoms 
from  a  lack  of  vitality,  super- 
induced by  the  limitations  as 

FIG.   198. — Right  Dorsal,  Left  Lumbar  Curve  with  .     '  .     . 

Displacement  of  Body  to  the  Right.  to   CXCrClSC   and   activity,    COnSC- 

quent  on  the  deformity,  and  to 

the  impairment  of  circulation  and  respiration  by  the  deformity  of  the 
chest. 

Interruption  in  the  functions  of  the  lungs,  heart,  liver,  stomach, 
and  intestines  is  occasionally  seen  in  severe  cases,  shortness  of 
breath  and  indigestion  being  frequent  symptoms  in  the  severer  cases 
in  adult  life.  In  the  severest  cases  in  adults  the  patients  are  thin,  and 
as  a  rule  lack  resistance,  being  especially  prone  to  pulmonary  tubercu- 
losis. 

Deformity. — The  chief  symptom  of  lateral  curvature  is  the  dis- 
tortion. 

The  curves  of  the  spinal  column  vary  in  degree,  situation,  and 


220 


ORTHOPEDIC  SURGERY 


extent.     There  are,  however,  common  types,  which  it  is  convenient 
to  bear  in  mind  in  considering  the  subject  of  treatment. 

Structural  and  Postural  Curves. — Curves  will  be  found  to  vary 
not  only  in  their  localization  and  their  amount  of  rotation,  but  also 
in  their  rigidity.  This  variation  is  due  to  the  variation  in  the  amount 
of  structural  change.  For  clinical  purposes  it  is  convenient  to  apply 


Fia.    199. — Left    Total     Curve.    Showing     Elevated    Left   Shoulder. 


the  term  structural,  fixed,  or  liobitual  curves  to  those  with  evident 
changes  in  the  tissues,  and  functional  or  postural  to  those  curves  with- 
out definite  structural  changes.  The  latter  are  flexible  and  easily 
corrected  by  the  patient's  effort,  by  lying  down,  or  by  suspension. 
In  such  rotation  is  not  a  prominent  symptom.  The  terms  primary  and 
secondary  curves  are  also  used  to  define  the  relative  clinical  impor- 
tance or  severity  of  the  two  curves  present. 


LATERAL  CURVATURE  OF  THE  SPINE 


221 


Lateral  curvature  either  involves  the  whole  spine  in  one  curve, 
termed  by  some  writers  total  scoliosis,  or  it  is  chiefly  confined  to  a 

region  or  regions  of  the  spine, 
when  the  curvature  is  called  cer- 
vical, dorsal,  or  lumbar  scoliosis. 
These  are  defined  as  right  or  left, 
according  to  the  direction  of  the 
convexity  of  the  curves. 

What  is  termed  double  scoli- 
osis is  met  when  an  upper  curve 
is  found  in  one  direction  and  a 
lower  in  the  opposite,  or  triple 
scoliosis  when  three  curves  are 
present. 

If  one  lateral  curve  occurs 
in  the  middle  region  of  the  spi- 
nal column,  one  or  two  other 
compensating  curves,  above  or 
below  the  deformity,  are  of  ne- 
cessity developed  in  opposite  di- 
rections, to  preserve  the  pa- 
tient's balance,  in  order  that 
the  head  be  kept  erect  and  in 
the  median  line.  In  some  in- 
stances one  of  the  compensating 
curves  is  of  an  equal  prominence 
with  the  so-called  primary  curve, 
in  which  case  the  spinal  column  will  present  the  S-shaped  curve  which 
is  characteristic. 

The  curves  are  rarely  limited  exactly  to  definite  anatomical  regions 
of  the  spinal  column;  the  upper  curve  may  be  so  long  as  to  include 
all  of  the  dorsal  and  upper  lumbar  vertebrae.  Again,  the  lower  curve 
may  be  so  long  as  to  invade  nearly  the  whole  of  the  dorsal  region, 
the  compensation  taking  place  in  the  upper  part  of  the  cervical  region. 
Cervical  Curvature. — The  cervical  or  cervico-dorsal  curves  are  the 
least  common  form  of  lateral  curvature,  occurring  in  about  36  per 
cent  of  cases,1  and  are  convex  to  the  left  more  often  than  to  the 
right. 

This  form  is  most  commonly  accompanied  by  a  long  compensatory 
lower  curve.     There  is  elevation  of  the  shoulder  on  the  convex  side 

1  Joachimsthal  ;  Hdbch.  d.  orth.  Chir.,  1903,  iii  ,  708. 


FIG.  200. — Right  Dorsal  Curve,  Showing  Ele- 
vation of  Right  Shoulder,  Prominent  Left 
Hip,  and  Rotation  of  Right  Chest  Back- 
ward. 


222 


ORTHOPEDIC  SURGERY 


of  the  lateral  curve  at  the  level  of  the  shoulders  and  the  head  is  tipped 
to  the  side  of  the  concavity  of  the  cervical  curve. 

Dorsal  Curvature. — The  most  common  dorsal  curve  is  with  the 
convexity  to  the  right.  In  these  cases  the  right  shoulder  will  be  raised, 
the  right  shoulder  blade  will  project  backward  more  prominently  than 
the  left,  and  will  be  at  a  higher  horizontal  level  and  farther  from 


FIG.  201.— Lateral  Curvature  Due  to  Empy- 
ema  of  Right  Chest.  Five  months  after 
operation. 


FIG.  202. — Congenital   Lateral   Curvature  As- 
sociated with  Absence  of  Ribs. 


the  median  line  of  the  trunk.  The  back,  just  below  the  scapula,  will 
be  more  rounded  backward  on  the  right  side  and  more  flattened  on 
the  left.  In  front,  in  well-marked  cases,  the  breast  and  front  of 
the  chest  will  be  more  prominent  on  the  left  than  on  the  right  side. 

In  addition  to  the  curve  there  is  displacement  of  the  whole  trunk 
to  the  right  side,  as  a  result  of  which  the  right  arm,  when  hanging, 
will  be  free  from  the  side,  while  the  left  arm,  when  hanging  down, 
necessarily  strikes  the  hip. 

There  is  also,  unavoidably,  a  change  in  the  outline  of  the  sides  of 


LATERAL  CURVATURE  OF  THE  SPINE  223 

the  back.  The  sides,  instead  of  being  symmetrical,  as  seen  from  the 
back,  will  be  different;  one  side  being  unnaturally  straight,  and  the 
other  more  than  normally  hollowed. 

The  normal  backward  physiological  curve  in  the  dorsal  region  may 
be  diminished  so  that  the  upper  back  is  abnormally  flat,  or  it  may  be 
increased  so  that  the  dorsal  region  is  abnormally  bowed.  Dorsal 
curves  exist  alone  in  about  20  per  cent,  and  combined  with  other 
curves  in  about  30  per  cent,  of  the  cases. 

Lumbar  Curvature. — Dorso-lumbar  or  lumbar  curvature  manifests 
itself  by  a  prominence  of  one  of  the  hips;  the  one  on  the  side  of  the 
concavity  of  the  curve  appearing  in  the  contour  of  the  trunk  higher 
than  on  the  other  side,  as  the  iliac  crest  is  less  covered  by  overlying 
tissue.  It  is  often  termed  a  "high  hip,"  but  incorrectly;  measure- 
ment showing  no  difference.  In  well-marked  lumbar  curvature  there 
is  also  a  fulness  in  the  back  on  the  convex  side,  above  the  crest 
of  the  ilium,  and  a  corresponding  hollowing  on  the  other.  A  marked 
difference  in  the  outlines  of  the  two  sides  of  the  back,  already  men- 
tioned, is  seen  in  this  form  of  curvature.  Lumbar  curves  exist  alone 
in  something  over  10  per  cent  of  the  cases,  but  are  seen  most  often 
associated  with  other  curves. 

A  combination  of  lumbar  and  dorsal  curves  in  opposite  directions, 
or  compound  curves  as  they  have  been  termed,  will  present  the  fea- 
tures of  both  varieties,  the  distortion  of  the  most  pronounced  curve 
being  predominant. 

Rotation. — As  was  explained  under  the  head  of  pathology,  it  is  im- 
possible for  any  curvature  to  take  place  in  the  spinal  column  without 
being  accompanied  by  rotation,  and  the  prominence  of  rotation  in 
lateral  curvature  is,  in  a  general  way,  a  measure  of  the  severity  of 
the  case. 

Rotation  is  always  toward  the  convex  side  of  the  lateral  curve; 
but  in  childhood  the  so-called  total  scoliosis  often  shows  a  general 
backward  prominence  of  one  side  (spoken  of  as  reverse  rotation,  retro- 
torsion,  concave  torsion,  paradoxical  scoliosis,  etc.),  and  the  back- 
ward projecting  shoulder  will  often  be  found  on  the  concave  rather 
than  the  convex  side.  This  occurs  only  in  a  flexible  spinal  curve, 
where  the  compensatory  curve  is  not  easily  recognized  or  established. 
It  is  perhaps  the  initial  stage  of  the  ordinary  type  of  scoliosis,  the 
long  curve  being  afterward  divided  into  two  sections. 

When  school  children  are  examined  irrespective  of  symptoms  com- 
plained of,  many  postural  curves  not  brought  to  the  surgeon  for 
examination  are  seen.  Of  these,  total  curves  will  be  found  the  most 


224  ORTHOPEDIC  SURGERY 

common,  and  of  these,  the  one  with  the  convexity  to  the  left  is  the 
most  frequent. 

VARIETIES   OF   LATERAL   CURVATURE. 

Congenital  scoliosis  and  its  causes  have  been  already  alluded  to; 
acquired  scoliosis  appears  most  often  in  the  following  forms: 

Rhachitic  Lateral  Curvature. — This  form  occurs  in  rhachitic  chil- 
dren, but  it  is  not  so  common  a  curve  as  the  simple  posterior  curve 


FIG.  203. — Left   Lumbo-dorsal    Curve. 


which  appears  as  a  backward  prominence  in  the  lumbar  region  in  so 

many  cases  of  rickets.     It  is  probable  that  if  cases  with  rickets  were 

more  carefully  examined,  scoliosis  would  be  more  frequently  observed. 

Difference  in  Length  of  Legs. — A  slight  difference  in  the  length 


LATERAL  CL'RVATURE  OF  THE  SPINE 


225 


of  the  lower  limbs  is  the  rule.  But  development  of  lateral  curvature 
directly  from  this  cause  is  not  invariable,  because  in  cases  of  scoliosis 
a  notable  difference  in  the  length  of  the  lower  limbs  is  detected  in 
about  the  same  proportion  of  cases  as  in  normal  children.  In  children 


FIG.  204. — Severe  Curvature  due  to   Rickets. 


with  marked  inequality  in  the  length  of  the  legs  and  with  diminished 
resistance  in  the  vertebral  column,  scoliosis  may  follow. 

Paralytic  Lateral  Curvature. — In  a  certain  number  of  cases  of 
paralysis  of  the  muscles  of  the  back  lateral  curvature  of  the  spine  is 
found.  The  curvature  may  be  toward  the  side  of  the  paralyzed  mus- 
cles or  away  from  them.  This  form  of  lateral  curvature  is  most  com- 
monly developed  after  infantile  paralysis,  but  the  distortion  may  be 
seen  after  spastic  paralysis,  progressive  muscular  hypertrophy, 
syringomyelia,  and  similar  affections. 

Torticollis. — Congenital  torticollis,  if  uncorrected,  is  always  fol- 
lowed by  scoliosis.  Inequality  of  vision  and  hearing  and  congenital 


226 


ORTHOPEDIC  SURGERY 


conditions  causing  the  head  to  be  held  to  one  side  are  other  possible 
causes  of  scoliosis. 

Lateral  Curvature  from  Contracture  of  the  Chest. — Lateral  curva- 
ture may  follow  empyema.  In  the  purest  forms  of  this  type,  the 
contracted  side  of  the  chest  is  on  the  side  of  the  concavity  of  the 
lateral  curve. 

A  curvature  is  sometimes  observed  in  connection  with  organic 
heart  disease  in  children. 

Lateral  Curvature  from  Occupation. — Any  occupation  which  ne- 
cessitates faulty  attitudes  for  long  periods  daily,  favors  the  development 


FIG.  205. — Severe  Case  of  Spastic  Paralysis  in  a  Patient  who  had  never  Walked  and  who  from 
Childhood  had  Sat  to  One  Side.      The  patient  is  now  an  adult. 

of  a  spinal  curve,  but  lateral  curvatures  of  severe  type  due  to  ordinary 
occupation  are  not,  as  a  rule,  common,  for  the  reason  that  laborious 
occupations  are  not,  in  general,  entered  upon  until  an  age  when  the 
spinal  column  has  a  sufficient  amount  of  resistance  to  withstand  the 
superimposed  weight  without  developing  great  structural  change. 

Scoliosis  seen  in  school  children  is  in  reality  generally  an  occupa- 
tion deformity,  resulting  as  it  does  from  the  constant  assumption  of 
faulty  attitudes,  which  produce  abnormal  pressure  and  strain  upon 
growing  spinal  columns  lacking  in  structural  resistance. 

Alteration  in  the  shape  of  the  vertebra;  from  disease  (Pott's  dis- 
ease, osteomyelitis  of  the  spine,  and  spondylitis  deformans)  may  cause 
lateral  curvature.  It  may  also  occur  in  sacro-iliac  disease  as  the  result 
of  muscular  spasm.  Ischias  scoliotica,  referred  to  also  as  scoliosis 


LATERAL  CURVATURE  OF  THE  SPINE  227 

neuromuscularis,  or  neuropathica  or  ischiatica,  is  a  term  which  has 
been  applied  to  lateral  curvature  in  the  lower  part  of  the  spinal  column 
occurring  in  connection  with  sciatica  and  lumbago. 

DIAGNOSIS. 

The  method  of  examination  of  a  case  of  lateral  curvature  is  as 
follows : 

The  patient's  back  should  be  bared  to  the  level  of  the  trochanters, 
and  the  arms  should  be  allowed  to  hang  free.  In  young  children 
when  feasible  the  whole  figure  should  be  unclothed  and  the  position 
of  the  lower  extremities  inspected.  The  most  natural  attitude  in 
standing  should  be  noted  and  also  the  position  of  the  patient  in  an 
attempt  to  stand  in  as  straight  a  position  as  is  possible;  the  tips  of 
the  spinous  processes  are  to  be  marked  with  a  skin  pencil,  and  also 
the  ends  of  the  scapulae.  To  determine  the  central  line  a  string,  to 
which  a  slight  weight  is  attached,  can  be  used  as  a  plumbline  to 
show  a  perpendicular.  It  should  be  made  to  hang  so  as  to  pass  through 
the  cleft  of  the  buttock,  and  the  deviation  of  the  spine  from  this 
vertical  line  can  be  noted.  The  distance  of  the  tips  of  the  scapulas 
from  this  central  line  should  be  recorded,  and  also  the  distances  from 
this  line  to  the  points  of  greatest  curvature  of  the  line  of  the  spinous 
process.  The  slope  of  the  shoulders,  the  outlines  of  the  sides  of  the 
trunk,  and  the  contour  of  the  back,  as  well  as  any  lack  of  symmetry 
or  unilateral  fulness,  should  be  carefully  recorded.  If  a  side  deviation 
is  observed,  the  patient  should  be  suspended  by  means  of  a  head  sling 
and  also  made  to  lie  in  a  recumbent  position  upon  the  face.  A  marked 
alteration  of  the  curvature,  contour,  or  outlines  following  removal  of 
the  superincumbent  weight  is  of  particular  importance.  If  the  curve 
disappears  under  these  conditions,  it  is  to  be  classed  as  chiefly  postural. 
If  it  does  not  disappear,  it  is  to  be  considered  structural. 

The  patient  should  then  bend  forward  with  the  knees  straight  and 
the  arms  hanging  until  the  trunk  is  horizontal.  In  the  normal  spine 
the  two  sides  of  the  back  will  be  on  a  level  when  viewed  in  this  posi- 
tion. Rotation  of  the  ribs  or  lumbar  vertebrae  due  to  structural 
changes  is  shown  by  a  greater  upward  prominence  of  the  side  of  the 
back  which  has  rotated  backward. 

The  flexibility  of  the  spine  should  be  tested  by  causing  the  patient 
to  stand  first  with  one  foot  and  then  the  other  upon  a  series  of  blocks 
half  an  inch  in  thickness,  and  testing  what  height  can  be  placed  under 
the  patient's  foot  without  preventing  her  from  standing  upon  both 
legs  with  the  limbs  straight,  without  flexion  at  the  knee;  this  tests 


228  ORTHOPEDIC  SURGERY 

the  lateral  flexibility  in  the  lower  part  of  the  spinal  column.  In  testing 
the  flexibility  higher  up,  the  patient  should  be  seated  on  a  stool,  and 
one  hand  of  an  assistant  be  placed  upon  her  side,  above  the  crest  of 
the  ilium,  while  the  other  hand  should  be  placed  upon  the  crest  of  the 
ilium  of  the  opposite  side.  The  patient  should  then  be  directed  to 
bend  sideways  toward  the  side  of  the  higher  hand,  and  the  amount 
of  this  motion,  without  tilting  of  the  pelvis,  is  to  be  noted. 

It  is  not  always  necessary  to  examine  the  front  of  the  patient's 
trunk  in  the  case  of  older  patients.     \Yhen  this  is  done,  the  projection 


FIG.  206. — Measurement  of  the  Rotation   of  the   Ribs  in  the  Horizontal   Position  by  the  Levelling 
Trapezium  of   Schulthess.      (Schulthess. ) 

of  the  ribs  in  front,  and  the  difference  in  the  prominence  or  flatness 
of  the  two  breasts,  the  deviation  of  the  tip  of  the  sternum  and  of  the 
umbilicus  from  the  median  line  are  of  importance,  as  indicating  the 
amount  of  structural  change  which  has  taken  place.  Asymmetry  of 
outline  is  always  to  be  more  clearly  seen  from  the  front  than  from 
the  back  of  any  patient. 

The  accidental  assumption  of  a  faulty  attitude  does  not  justify  a 
diagnosis  of  lateral  curvature  but  the  habitual  assumption  of  such 
a  position,  when  the  patient  stands  in  the  attitude  of  ease  and  greatest 
comfort,  indicates  an  abnormal  condition.  The  existence  of  slight 
grades  of  lateral  curvature  is  made  more  evident  by  allowing  the 
patient  to  stand  for  a  minute  before  beginning  the  examination,  in 
order  to  obtain  the  relaxed  position  due  to  beginning  muscular  fatigue. 

The  amount  of  structural  change  is  indicated  by  the  amount  of 
stiffness  and  by  the  slight  change  in  the  curves  and  asymmetrical 


LATERAL  CURVATURE  OF  THE  SPINE  229 

symptoms  as  the  patient  alters  the  position  by  standing,  lying,  bend- 
ing, twisting,  and  hanging,  and  by  the  extent  of  the  rotation. 

Lateral  curvature  is  not  infrequently  confounded  with  Pott's  dis- 
ease. In  pronounced  lateral  curvature,  the  lateral  twist  and  the  rota- 
tion are  essentially  different  from  the  curve  of  Pott's  disease,  which 
is  chiefly  an  antero-posterior  curve. 

METHODS  OF  RECORDING  LATERAL  CURVATURE. 

Of  the  many  methods  for  recording  lateral  curvature  the  simplest, 
if  of  sufficient  accuracy,  are  to  be  preferred. 

If  the  measurements  are  noted  of  the  distance  of  fixed  points  on 
the  spine  from  a  plumb  line  and  these  are  recorded,  the  curves  can 
serve  as  a  measure  for  future  comparison. 

If  a  graphic  record  is  desired,  a  simple  method  can  be  employed 
if  the  patient  with  the  pelvis  secured  is  placed  with  the  bared  back 
against  a  transparent  sheet  of  celluloid  secured  in  a  fixed  position 
focussed  on  the  portion  of  the  back  showing  the  greatest  rotation  of 
the  spine. 

Photography,  if  carefully  employed,  is  of  assistance.1  For  this 
purpose  the  spinous  processes  should  be  marked. 

The  patient  should  stand  with  the  back  square  to  the  camera.  For 
standardizing  and  comparison  the  adoption  of  a  fixed  distance  is  de- 
sirable. An  oblique  light  gives  the  best  contour  in  the  photograph, 
but  the  light  coming  from  directly  behind  gives  a  fiat  picture  with  no 
detail.  Light  from  more  than  one  source  gives  a  picture  with  but 
little  contour. 

PROGNOSIS. 

In  the  larger  number  of  cases  the  affection  is  a  self-limited  one, 
occasioning  slight  deformity,  which  persists  through  life,  causing  no 
trouble  and  recognized  only  by  the  dressmaker  or  by  some  near  rela- 
tive. In  other  cases,  however,  the  deformity  increases,  and  a  pitiable 
distortion  follows,  causing  a  marked  deformity,  perhaps  neuralgic 
pain,  and  ill  health. 

It  is  impossible  to  state  positively  in  what  instances  an  increase 
of  the  curve  will  take  place  and  when  they  can  be  relied  upon  to  remain 
stationary.  It  may,  however,  be  said  that  when  the  physical  condi- 
tion during  the  growing  period  remains  constantly  below  the  proper 
standard,  and  when  the  patient's  growth  is  rapid,  an  increase  of 
curve  is  to  be  apprehended.  The  decrease  or  diminution  of  lateral 

1  Ueber  die  Messmethoden  des  Riickens.     Hovorka,  Wien,  1904. 


230  ORTHOPEDIC  SURGERY 

curvature  from  simple  growth  without  treatment  is  not  to  be  ex- 
pected. Sometimes  the  disease  may  remain  to  a  slight  extent  during 
early  life,  developing  an  increase  at  a  period  past  middle  life.  Such 
cases  are  dependent  upon  a  loss  of  general  health  and  upon  trophic 
changes  occurring  at  this  period  of  life. 

In  determining  the  prognosis  the  probable  period  of  growth  ahead 
is  to  be  borne  in  mind.  This  can  be  ascertained  by  the  patient's  height, 
the  hereditary  tendency  toward  height  as  ascertained  by  the  height  of 
the  parents  and  the  parents'  families.  This  is  of  importance,  because 
the  completion  of  growth  exerts  a  powerful  influence  in  arresting 
progress  of  the  curvature. 

In  general  it  may  be  said  that  if  a  patient  has  gained  full  height 
and  development  in  figure,  any  increase  in  growth  is  not  often  to  be 
expected,  and  that  an  increase  in  curve  is  not  probable  after  the 
osseous  system  has  become  thoroughly  formed  and  the  strength  of 
the  spinal  column  established ;  except  in  the  severe  cases,  where  there 
is  more  tendency  to  slight  increase,  even  during  adult  life. 

Prognosis  under  Treatment. — Cases  of  postural  scoliosis  should 
be  completely  cured  by  proper  treatment.  If  cases  of  scoliosis  have 
little  structural  change,  improvement  can  always  be  obtained,  and  in 
younger  children  this  can  be  generally  made  a  permanent  cure.  In 
cases  with  marked  structural  change  in  the  growing  years,  diminution 
of  the  curve  is  to  be  expected  to  follow  adequate  treatment.  In  rigid 
cases  an  improvement  of  condition  and  carriage  can  be  hoped  for. 
The  prospects  of  treatment  are,  of  course,  better  when  it  can  be  car- 
ried on  during  the  period  of  growth. 

PREVENTIVE   MEASURES. 

Certain  measures  are  of  importance,  not  only  in  preventing 
scoliosis,  but  as  a  preliminary  to  treatment  when  scoliosis  exists. 

Attitude  at  School. — Correct  methods  of  sitting  during  school, 
especially  in  writing,  are  of  importance,  and  the  matter  has  received 
much  attention.  It  is  perfectly  evident  that  the  continued  assumption 
of  a  curved  and  twisted  position  is  a  competent  cause  of  scoliosis,  and 
figures  show  wherever  they  are  taken  a  constant  increase  in  the 
proportion  of  scoliosis  among  children  during  school  life.  For  this 
reason  the  use  of  proper  school  furniture  is  of  great  importance  and 
the  literature  of  the  subject  will  be  found  in  the  reference.1 

It  is  also  essential  to  prevent  persistent,  faulty  attitude  at  home 
as  well  as  at  school. 

1  Cofton  :  American  Physical  Education  Review,  December,  1904. 


LATERAL  CURVATURE  OF  THE  SPINE 


231 


School    Hygiene   and    School    Gymnastics. — Proper    lighting    of 
schoolrooms  and  the  correct  placing  of  blackboards  are  essential  in 
favoring  proper  attitudes.     The  avoidance  of  long  sitting  periods  by, 
introducing  gymnastic  exercises  and  changes  of  position  is  of  im- 
portance. 

Correct  Carriage. — Faulty  attitudes  are  frequently  assumed  in 
walking  and  in  standing,  especially  by  young  children.  The  inclination 
to  stand  upon  one  leg  is  usually  a  habit,  but  in  some  cases  it  may  be 
due  to  a  muscular  weakness  of  one  limb  or  of  a  knee  or  ankle.  The 
habit  is  to  be  corrected  by  drill  or  by  muscular  exercise,  and  by  en- 
couraging activity  with  the  necessary  constant  change  of  position. 
Incorrect  habits  in  sitting  at  home  are  to  be  remedied  by  insisting  that 


FIG.  207.— Photograph  Showing  Attitude  with  Improper  Clothing. 

the  children  with  curvature  shall  not  sit  curled  up  or  bent  over  in 
reading,  but  that  they  shall  sit  in  suitable  chairs  and  hold  the  book 
correctlv. 


232  ORTHOPEDIC  SURGERY 

Attitude  during  Sleep. — The  most  common  attitude  in  sleep  is 
upon  the  side,  but  decubitus  upon  the  back  is  more  common  than  on 
either  single  side.  The  right  side  is  more  commonly  lain  on  than 
the  left,  but  the  difference  is  slight;  young  children  and  men  not 
infrequently  lie  upon  the  belly,  but  the  attitude  is  not  so  often  assumed 
by  women  or  growing  girls. 

In  ordinary  cases  the  precautions  at  night  which  should  be  ob- 
served are  that  the  patient  should  not  be  allowed  to  sleep  with  many 
pillows  and  that  the  bed  should  be  a  firm  one.  The  child  should  not 
be  allowed  to  assume  a  twisted  position,  but  should  lie  upon  the  back 
or  the  side  of  the  greatest  concavity.  In  threatening  cases  measures 
are  necessary  to  preserve  a  proper  position.  This  can  be  done  by 
means  of  bed  frames,  described  under  Pott's  disease. 

Proper  Clothing. — The  modern  style  of  clothing  in  growing  chil- 
dren predisposes  to  round  shoulders,  and  is  a  handicap  to  the  treat- 
ment of  scoliosis.1  The  use  of  side  garters,  which  fasten  tightly 
drawn  long  stockings  to  waists  dragging  upon  shoulder  straps  and 
shoulders,  is  to  be  avoided.  This  can  be  done  by  the  use  of  round 
garters  or  attaching  the  garters  to  properly  constructed  shoulder 
straps  independent  of  the  waist  and  designed  to  draw  the  shoulders 
backward  and  not  forward.  Heavy  petticoats  should  not  be  attached 
to  waist  with  shoulder  straps  dragging  upon  the  shoulders  of  grow- 
ing girls.  This  can  also  be  avoided  by  the  use  of  union  suits  for 
underwear  and  light  petticoats. 

TREATMENT. 

Several  difficulties  are  to  be  met  in  treating  lateral  curvature.  As 
the  affection  is  active  during  the  period  of  growth,  treatment,  to  be 
efficient,  must  be  carried  on  for  a  long  time,  and  is  tedious  to  the  sur- 
geon and  irksome  to  the  patient.  Furthermore,  as  the  disease  is  cne 
that  does  not  threaten  life  and  is  slow  and  uncertain  in  its  outcome,  it 
is  sometimes  difficult  to  enforce  the  proper  treatment  for  the  requisite 
length  of  time.  Cases  will  be  brought  to  the  surgeon's  care  presenting 
varying  degrees  of  deformity  and  needing  different  grades  of  treat- 
ment. Cases,  however,  can  be  grouped  in  two  classes : 

I.  Those   with  slight  structural  change  and  curves  in  the  main 
flexible. 

II.  Those  with  structural  change  showing  in  curves  which  are 
fixed. 

1  E.  H.  Bradford :  Trans.  Am.  Orth.  Assn.,  vol.  x.,  162. 


LATERAL  CURVATURE  OF  THE  SPINE 


233 


J 


\\ 


I.    TREATMENT  OF  CASES  WITH  SLIGHT  STRUCTURAL  CHANGE  AND 
CURVES  IN  THE  MAIN  FLEXIBLE. 

Postural  Treatment. — The  postural  treatment  consists  in  the  cor- 
rection of  faulty  habits,  the  development  of  weak  muscles,  and  the 
retention  of  proper  attitudes.  As  a  raw  recruit  is  taught  the  position 
and  carriage  of  the  soldier,  so  children,  if  faulty  habits  of  attitude 
are  present,  are  to  be  drilled  into  standing  and  walking  in  correct 
attitudes,  and  the  spine  is  to  be  made 
equally  flexible  in  all  directions  if  '\ 

there  is  any  degree  of  stiffness  pres- 
ent. This  method  is  suited  for  the 
simplest  cases  of  beginning  curva- 
ture. To  be  thoroughly  carried  out, 
it  requires  that  the  patient  should 
daily  be  exercised  in  walking,  stand- 
ing, and  sitting  properly  for  a  speci- 
fied time  under  the  direction  of  some  - 
competent  person.  The  principles  of 
the  "  setting-up  "  drill  of  recruits  in 
all  armies  are  applicable,  with  modi- 
fications, to  patients  of  this  class. 
When  resting  during  the  hour  of 
drill  the  patient  should  remain  re- 
cumbent. At  other  times,  such  pre- 
caution should  be  taken  as  will 
prevent  the  persistence  for  any 
length  of  time  of  a  faulty  attitude. 
This  should  not  be  done  (out  of  the  drill  time)  by  constant  correction, 
but  by  the  proper  arrangement  of  the  daily  routine  as  to  play  and 
school  to  prevent  excessive  mental  or  physical  fatigue  and  a  super- 
vision of  the  chairs  when  reading  and  studying.  Walking,  running, 
and  active  games  should  be  encouraged,  while  reading,  except  in 
proper  position,  should  be  discouraged. 

Gymnastics. — In  many  early  cases  of  scoliosis  the  faulty  attitudes 
are  clearly  the  result  of  muscular  weakness.  The  increase  in  height 
has  not  been  accompanied  by  a  corresponding  development  in  muscle. 
This  condition  is  frequently  met  in  rapidly  growing  children,  and  is 
one  of  the  common  causes  of  lateral  curvature.  Here  proper  gym- 
nastics are  indicated,  but  they  should  be  prescribed  and  carried  out 


FIG.  208. — Diagram  of  the  Adjustable  School 
Chair  Adopted  by  the  Boston  Schoolhouse 
Commission.  (F.  J.  Cotton.) 


234  ORTHOPEDIC  SURGERY 

with  much  care.  In  the  more  marked  cases  the  children  are  unable 
to  bear  much  exercise  without  fatigue.  Those  exercises,  therefore, 
chiefly  needed  in  correcting  the  deformity  should  be  the  only  ones 
prescribed.  The  usual  class-work  of  a  gymnasium  is  to  be  avoided, 
as  such  cases  require  the  individual  attention  of  a  competent  person, 
who  will  see  that  no  faulty  position  is  taken  during  the  exercises, 
and  each  case  must  be  regarded,  as  far  as  exercises  are  concerned,  as 
a  separate  problem  to  be  worked  out  individually. 

LIGHT  GYMNASTICS. — It  is  not  a  difficult  matter  to  devise  simple 
and  practical  exercises  to  develop  the  muscles  chiefly  at  fault. 

General  developmental  exercises  for  the  back,  shoulders,  and  abdo- 
men, when  taken  with  the  spine  straight  and  the  carriage  of  the  body 
correct,  constitute  the  best  general  scheme  for  the  treatment  of  such 
cases.  Cases  will  be  seen  of  such  feeble  muscular  strength  that  it  is 
advisable  to  begin  with  those  which  demand  the  least  muscular  effort 
in  maintaining  a  symmetrical  attitude.  For  these  cases  exercises  with 
the  patient  recumbent  are  desirable. 

If  the  patient  has  gained  sufficient  strength,  a  series  of  light 
dumb-bell  exercises  with  bells  weighing  from  one  to  five  pounds  can 
be  prescribed,  carried  on  with  the  patient  recumbent,  similar  to  those 
just  mentioned.  Care  should  be  taken  that  they  are  correctly  per- 
formed. 

After  this,  follow  light  symmetrical  dumb-bell  exercises  with  the 
patient  standing  in  a  correct  position.  The  work  of  the  patient  should 
be  tabulated  and  carefully  graded.  This  is  to  be  followed  by  heavier 
work  of  the  same  general  type. 

\Yhether  light  or  heavy  exercises  are  used,  persistence  is  necessary 
for  success.  It  is  needless  to  add  that  the  patient  should  exercise 
under  careful  supervision,  rest  being  prescribed  as  a  part  of  the  daily 
treatment,  the  amount  of  work  being  regulated  each  day. 

Flexibility  Exercises. — In  some  instances  of  postural  curves  ab- 
normal centres  of  motion  of  spinal  curves  and  asymmetrical  spinal 
flexibility  will  be  found  to  exist. 

This  is  to  be  corrected  by  exercises  to  restore  normal  spinal  mo- 
bility not  designed  especially  for  muscular  development,  analogous 
to  the  measures  employed  by  contortionists  to  develop  abnormal  joint 
flexibility. 

These  exercises  need  to  be  carefully  planned  for  each  case,  and 
with  checks  to  prevent  motion  where  free  motion  in  the  spinal  column 
already  exists,  and  to  develop  motion  where  spinal  flexibility  is  less 
than  normal. 


LATERAL  CURVATURE  OF  THE  SPINE  235 

Appliances. — In  postural  curves,  where  weak  muscles  are  present, 
it  is  sometimes  advisable  to  furnish  light  appliances  to  check  faulty 
attitudes,  these  to  be  worn  at  the  time  in  the  day  when  the  child 
shows  gradual  muscular  fatigue  and  droops  into  faulty  attitudes 
most  readily.  These  appliances  should  be  light,  easily  adjustable,  and 
check  motion  only  in  the  desired  direction. 

Intermittent  Correction. — During  this  period,  not  only  are  the 
measures  for  muscular  development  and  the  development  of  normal 
flexibility  required  in  the  treatment  of  postural  and  slight  structural 
curves  needed,  but  also  more  thorough  measures. 

Flexibility  exercises  can  be  given  by  means  of  various  appliances 
designed  for  the  purpose,  and  patients  brought  daily  to  institutions 
or  specialists'  offices  equipped  for  the  purpose  can  receive  the  necessary 
treatment. 

But  in  the  majority  of  cases  such  treatment  is  not  feasible  for 
as  long  a  period  as  is  needed  in  the  graver  cases.  Simple  forms  of 
appliances,  suitable  for  daily  home  treatment,  are  necessary,  which 
can  be  effectively  furnished. 

Simple  appliances  can  be  made  exerting  correcting  pressure  by 
means  of  weights,  lever  pressure,  strap  pressure — the  patient  standing 
suspended,  seated,  recumbent,  or  kneeling,  and  fixed  in  suitable  gas- 
pipe  quadrilateral  frames. 

The  chief  difficulty  is  not  in  securing  simple  apparatus  but  in 
obtaining  suitable  home  care. 

Fixation  Appliances. — Recumbency  being  inapplicable  for  a  long 
period,  and  gymnastics  being  possible  only  for  a  limited  portion  of 
the  day,  seme  form  of  appliance  which  checks  faulty  positions  is 
desirable  in  the  more  resistant  cases  of  this  type. 

II.  TREATMENT  OF  STRUCTURAL  CASES  WITH  FIXED  CURVES. 

The  treatment  of  this  class  of  spinal  curves  demands  the  exercise 
of  sound  judgment,  as  the  proper  management  of  these  cases  does  not 
consist  in  the  temporary  straightening  of1  a  curve,  which  will  relapse 
when  the  correcting  force  is  removed,  nor  the  constant  use  of  a  cor- 
recting jacket,  which  weakens  muscular  tissues. 

Measures  should  be  employed  successively  in  these  cases  suited  to 
the  conditions  during  the  growing  years;  not  for  a  few  months  or 
a  year,  but  until  the  bones  of  the  spinal  column,  as  well  as  muscles,  are 
able  to  bear  their  load  without  bending  abnormally  under  the  burden. 

In  seme  instances  it  is  advisable  to  disregard  the  curve  temporarily 


236 


ORTHOPEDIC  SURGERY 


and  devote  attention  to  the  patient's  general  condition,  with  the  em- 
ployment only  of  such  measures  as  are  needed  for  postural  curves. 

Where  curve  correction  is  needed  the  most  efficient  measure  is 
undoubtedly  by  applying  corrective  plaster  jackets. 


FIG.  209.  — Case  of  Scoliosis  Before  Treatment. 

Forcible  Correction  by  Means  of  Plaster  Jackets. — In  certain 
cases  the  curves  are  too  resistant  to  be  altered  materially  by  inter- 
mittent correction  or  gymnastic  exercises.  In  suitable  cases  attempts 
can  be  made  to  correct  the  curves  by  a  method  of  constant  pressure, 
as  it  has  been  demonstrated  that  the  shape  of  bone  is  altered  by  con- 
stant pressure.  For  the  application  of  this  method,  plaster  jackets 
should  be  applied  to  the  patient  in  as  corrected  a  position  as  possible. 


LATERAL  CURVATURE  OF  THE  SPINE 


237 


It  is  evident  that  this  method  of  correction  is  adapted  to  patients 
during  their  growing  period,  though  it  may  be  employed  occasionally 
in  older  cases. 

Corrective  plaster  jackets  can  be  applied  with  the  patient  in  a 
standing  or  sitting  position;  or  recumbent,  either  lying  on  the  face, 
back,  or  side.  Correcting  force  should  be  used  without  an  anaesthetic. 


FIG.  210.— Same  Case  as  Shown  in  Fig.  209  after  Three  Years.    Treatment  by 
Corrective  Plaster  Jacket. 

Suspension  or  a  traction  force  is  of  value ;  but  as  the  affected  por- 
tion of  the  spine  in  lateral  curvature  is  always  the  most  resistant 
portion,  the  most  economical  application  of  force  is  by  exercising  side 
pressure  rather  than  by  pulling  each  end.  Traction  force  used  to 
straighten  the  spine  by  itself  will  have  to  be  used  in  large  amounts  to 
be  effective.  Traction  force  may  also  be  used  in  the  recumbent 
position,  though  it  is  rarely  effective  as  a  traction  force  on  the  resist- 
ant curve. 

In  the  recumbent  position  the  patient  may  be  placed  with  the  back 


238  ORTHOPEDIC  SURGERY 

supported  on  a  frame  with  uprights  similar  to  that  used  in  the  applica- 
tion of  corrective  jackets  in  Pott's  disease,  except  that  the  pressure 
points  are  applied  in  the  back,  not  upon  the  transverse  processes,  but 
upon  the  backward  prominence  of  the  ribs.  Correction  of  lateral 
deviation  can  be  furnished  by  horizontal  traction,  if  necessary,  or  by 
side  pressure.  Felt  padding  is  needed  over  the  portions  of  the  body 
which  are  but  little  protected  by  fatty  tissue;  the  plaster  bandages 
should  be  applied  high  up  under  the  drooping  shoulder  and  over  the 
shoulder  from  behind,  across  the  neck.  \Yhen  the  plaster  is  suffi- 
ciently hardened  the  patient  can  be  lifted,  the  detachable  plates  which 
are  thoroughly  padded  remaining  in  the  jacket. 

A  simple  method  of  application  of  a  corrective  jacket  in  an  in- 
clined or  recumbent  position  is  to  secure  the  patient  firmly  in  the 
centre  of  the  four-upright  frame  used  for  applying  a  jacket  in  the  up- 
right position  and  inclining  the  whole  frame  backward.  The  correct- 
ing straps  will  need  readjustment  for  proper  correcting  force  when 
the  patient  is  changed  from  the  upright  to  the  recumbent  position. 

A  useful  method  in  recumbency  is  to  have  the  patient  lie  face 
downward,  on  two  strips  of  webbing  running  from  end  to  end  on  a 
horizontally  placed  oblong  gaspipe  frame.  There  are  two  transverse 
strips  of  webbing,  one  supporting  the  pelvis  and  another  the  shoul- 
ders. Side  pressure  is  secured  by  webbing  fastened  to  the  sides  of 
the  frame  running  around  the  trunk  and  securing  as  much  side  pres- 
sure as  desired.  The  patient  may  lie  with  the  thighs  extended  or 
flexed  to  any  desired  extent. 

In  applying  corrective  jackets,  it  is  to  be  remembered  that  there 
are  two  elements  of  the  deformity  demanding  correction — one,  the 
lateral  curve,  to  be  corrected  by  side  force ;  the  other,  the  rotation,  to 
be  corrected  by  a  twisting  force.  Any  use  of  force,  to  be  effective, 
must  be  met  by  counter-points  of  resistance  or  the  whole  spine  will 
be  pushed  to  one  side  or  twisted  as  a  whole. 

The  method  of  applying  plaster  jackets  described  by  Abbott  con- 
sists in  having  the  patient  lie  on  the  back  with  the  spine  strongly  flexed 
and  the  legs  suspended  at  right  angles  to  the  trunk.  This  is  accom- 
plished by  using  a  special  apparatus  which  is  a  rectangular  gaspipe 
frame  in  which  the  patient  lies  on  a  hammock  made  tighter  on  one  side 
than  on  the  other.  The  tight  side  being  under  the  convexity  of  the 
lateral  curve.  The  legs  are  fastened  to  a  bar  running  in  the  length  of 
the  frame  about  three  feet  above  the  level  of  the  patient.  \Yith  the 
spine  thus  sharply  flexed  bands,  running  to  the  sides  of  the  frame,  are 
arranged  to  correct  rotation  and  the  lateral  curve,  the  arm  of  the  low 


LATERAL  CURVATURE  OF  THE  SPINE 


239 


shoulder  is  placed  up  beside  the  head  and  pulled  toward  the  floor.  A 
heavy  pad  of  felt  is  placed  over  the  concave  side  of  the  curve  behind 
and  a  heavy  plaster  jacket  applied  to  the  patient  in  this  position.  The 
side  of  the  jacket  is  then  cut  out  over  the  concave  side  behind  and  on 
this  side  in  front  heavy  pads  are  drawn  through  holes  in  the  jacket  to 
press  the  thorax  back  into  the  hole  in  the  jacket. 

Such  jackets  hold  the  patient  in  a  flexed  position  with  one  arm 
held  away  from  the  side  and  are  unsightly  and  uncomfortable,  but 
from  the  knowledge  so  far  at  our  disposal  this  method  of  correction 


FIG.  2ii.—  Figures  Illustrating  Abbott  Jackets  After  Application.    Note  the  Windows  and  Padding. 

seems  to  be  somewhat  more  efficient  than  the  others  described.  This 
is  probably  because  the  flexed  position  of  the  spine  tends  to  unlock 
the  articular  processes  from  each  other  and  thus  to  allow  greater  ease 
of  correction,  especially  so  far  as  rotation  goes.  Indeed,  this  greater 
ease  of  correcting  rotation  makes  it  possible  to  produce  a  correction 
of  the  thorax  without  any  change  in  the  lateral  curve.  Many  cases 
apparently  "  overcorrected,"  so  far  as  attitude  goes,  show  in  the 
,r-ray  that  no  real  change  in  the  lateral  curve  has  been  made  by  the 
proceeding. 

With  regard  to  forcible  correction  by  plaster  jackets  in  general, 


240  ORTHOPEDIC  SURGERY 

it  must  be  remembered  that  in  severe  cases  the  deformity  at  the 
curved  portion  of  the  spine  is  of  such  a  character  that  immediate 
correction  is  quite  out  of  the  question,  and  that  "  overcorrection  " 


FIG.  212.— Figure  Illustrating  Method  of  Placing  Patient  in  Abbott  Frame. 

is  such  cases  is  absurd.  It  can,  however,  be  said  that  in  growing 
children  the  curved  portion  of  the  spine  may  be  influenced  toward 
straighter  growth  by  proper  jackets,  mild  cases  may  be  cured  and 
moderate  structural  cases  cured  or  very  greatly  benefited. 

This,  however,  implies  long-continued  after-treatment  in  the 
way  of  support,  and  it  is  probable  that  the  especial  method  by  which 
the  jacket  is  applied  is  of  less  importance  than  the  skill  and  experi- 
ence of  the  surgeon. 

High  dorsal  curves  are  improved  by  corrective  jackets  with  diffi- 
culty, because  satisfactory  counter-pressure  is  not  easily  applied  in 
these  curves,  if  resistant.  Lumbar  curves  are  also  generally  better 


LATERAL  CURVATURE  OF  THE  SPINE  241 

treated  by  other  means,  because  there  are  no  ribs  to  exert  side  pres- 
sure on  this  region  and  direct  side  force  cannot  be  exerted. 

Corrective  plaster  jackets  should  embrace  the  shoulders  and,  in 
cases  of  high  dorsal  curves,  the  neck,  and  should  not  be  removable. 
In  curves  in  the  upper  third  of  the  spine  a  head  support  adds  much  to 
the  corrective  power  of  the  jacket.  Windows  can  be  cut  in  the 
jacket  over  the  portion  of  the  trunk  where  pressure  is  undesirable,  as 
over  the  concavity  of  the  thorax.  At  first  the  patient  will  need  super- 
vision, but  later  can  go  about  freely.  Jackets  should  be  repeated  at 
short  intervals,  preferably  one,  two,  or  three  weeks,  and  applied  as 
long  as  further  correction  can  be  obtained.  This  stage  of  treatment 
is  followed  by  that  of  removable  jackets  and  exercises. 

The  relative  advantages  of  the  different  positions  of  the  patient  in 
the  application  of  a  corrective  jacket  are  as  follows : 

With  the  patient  standing  or  seated  it  is  much  easier  to  apply  the 
bandage  on  all  sides  of  the  patient  than  when  the  patient  is  recumbent, 
and  for  this  reason  is  preferable  in  applying  jackets  to  the  neck  and 
shoulders.  In  the  upright  position  the  position  of  the  head  relative  to 
the  thorax  is  that  usual  in  locomotion,  while  in  recumbency  an  altera- 
tion in  the  normal  thorax  takes  place.  Recumbently  applied  jackets 
are  therefore  less  comfortable  to  the  patients  than  those  applied  with 
the  patient  upright. 

If  the  patient  is  seated  it  is  easier  to  correct  lordosis  or  any  torsion 
of  the  pelvis  than  if  the  patient  is  standing,  but  in  the  seated  position 
the  surgeon  needs  to  take  especial  pains  in  arranging  the  seat  so  as 
to  enable  him  to  apply  a  jacket  which  will  hold  the  pelvis  firmly. 

Much  greater  correcting  pressure  can  be  applied  with  the  patient 
in  a  recumbent  position,  as  the  superimposed  weight  is  not  an  influence 
to  be  opposed.  In  recumbency  on  the  face  lordosis  can  be  overcome 
more  readily  than  if  the  patient  lies  upon  the  back.  It  is  less  easy, 
however,  to  secure  a  desirable  expansion  of  the  chest  and  arching 
backward  of  the  spine  in  the  dorsal  region  in  face  than  in  back  recum- 
bency. Where  there  is  much  rotation  to  be  corrected,  the  recumbent 
position  is  to  be  preferred.  Where  side  deviation  is  the  more  impor- 
tant feature,  the  upright  position  is  to  be  considered  also. 

The  amount  of  correcting  force  used  is  a  matter  of  judgment,  as 
is  also  the  time  when  corrective  pressure  treatment  should  be  discon- 
tinued. Skill  and  judgment  are  needed  in  the  application  of  braces  and 
removable  corsets,  after  corrective  jackets  are  discontinued.  Where 
the  spinal  column  is  not  strong  enough  to  carry  the  superincumbent 
weight  without  developing  abnormal  curves,  support  is  needed,  but 


ORTHOPEDIC  SURGERY 

the  constant  use  of  a  plaster  jacket  or  stiff,  heavy  corset  for  long 
periods,  i.e.,  a  year  or  more,  is  not  conducive  to  the  development  of 
strength  of  back.  Where  such  sup- 
ports are  needed  during  the  growing 
period,  the  appliance  should  be  light, 
easily  removed,  worn  without  dis- 
comfort, or  disfigurement  to  the  pa- 
tient, and  capable  of  exerting  effect- 
ive pressure  upon  the  various 
projecting  curves,  with  no  pressure 
upon  the  abnormal  concavities. 
Such  appliances  are  not  easily  made, 
and  should  be  adapted  to  the  needs 
of  each  case.  In  all  mid  or  upper 
dorsal  curves  they  should  extend 
above  the  shoulders.  They  can  be 
made  of  celluloid  or  light  stiffened 
leather,  with  large  windows  cut  over 
a  region  where  pressure  is  to  be 
avoided.  Efficient  light  steel  appli- 
ances can  be  made,  but  need  much 
painstaking  attention  in  design  and 
in  application.  Cases  of  this  class, 
after  the  cessation  of  active  correct- 
ive treatment,  need  careful  direc- 
tions as  to  recumbency,  exercises — 
the  hours  of  play,  study,  etc.,  and 

prolonged  supervision,  with  proper  record  taking  and  measurement. 
Resumption  of  active  corrective  treatment,  or  increasing  relaxation  in 
gymnastic  work,  will  depend  upon  the  progress  of  the  case. 

TREATMENT  BY  OPERATION. 

Operative  attempts  consisting  of  resection  of  the  projecting  ribs, 
performed  by  Volkmann  in  1889  and  Hoffa  1  in  a  few  instances,  have 
been  made  in  cases  in  which  the  distortion  of  the  ribs  resulting  from 
rotation  is  so  severe  as  to  preclude  the  possibility  of  correction  by 
other  means.  The  success  obtained  was  not  great. 

Successful  correction  of  disfiguring  rotation  by  multiple  osteotomy 
of  the  ribs  and  the  immediate  application  of  correcting  plaster  jackets 
is  a  method  which  was  employed  by  Hoke,  but  is  rarely  applicable. 

.  £.  orth.  Chir.,  1896,  401. 


FIG.  213. — Corrective  Plaster  Jacket  with 
Head-piece  Applied  for  the  Correction 
of  Scoliosis.  (Wullstein.) 


CHAPTER  XII. 
OTHER  DEFORMITIES  OF  THE  SPINE  AND  THORAX. 

THESE  deformities  are  either  congenital  or,  in  the  majority  of 
cases,  acquired,  dependent  on  general  conditions  which  in  the  mus- 
cular or  osseous  system,  limit  the  patient's  ability  to  maintain  the 
normal  erect  attitude. 

The  physiological  normal  curves  are  three,  forward  in  the  cervical 
region,  backward  in  the  dorsal,  and  forward  in  the  lumbar.  These 
curves  vary  according  to  the  habits,  occupation,  muscular  system,  sex, 
and  figure  of  the  individual. 

The  term  kyphosis  is  used  to  designate  an  increase  in  the  backward 
dorsal  physiological  curve,  and  the  term  lordosis  to  describe  an  increase 
in  the  forward  physiological  curve  in  the  lumbar  region. 

KYPHOSIS. 

An  increase  of  the  backward  curvature  of  the  spine  may  be  most 
noticeable  in  the  upper  part  of  the  spine,  or  may  practically  involve 
the  whole  dorsal  and  lumbar  spine.  It  occurs  ( i )  as  a  static  deform- 
ity, which  is  the  commonest  form  seen,  and  is  known  as  "  round 
shoulders";  or  (2)  as  the  result  of  an  abnormal  condition  of  the 
bones,  or  as  a  result  of  paralysis. 

i.  ROUND  SHOULDERS. 

The  term  round  shoulders  is  generally  applied  to  the  stooping  atti- 
tude which  results  from  the  muscular  relaxation  due  to  rapid  growth, 
to  the  assumption  of  improper  attitudes,  and  to  poor  general  condi- 
tion. It  is  generally  seen  in  children  and  is  likely  to  be  observed  at 
any  time  after  the  age  of  three  or  thereabouts. 

Causes. — The  affection  is  to  be  regarded  as  a  static  one  connected 
with  improper  muscular  support.  The  common  causes  are  as  follows : 

Improper  position  at  school  and  at  home.  Rapid  growth,  long 
hours  at  school,  insufficient  food,  improper  arrangement  of  clothing, 

243 


2-14 


ORTHOPEDIC  SURGERY 


and  too  long  an  active  day,  are  causes  inducing  muscular  debility  and, 
therefore,  favoring  round  shoulders. 

Symptoms. — In  round  shoulders  the  dorsal  physiological  curve  is 
increased,  the  head  is  run  forward,  the  shoulders  slope  forward,  the 


FIG.  214, — Round  shoulders.  Curve  of 
dorsal  and  lumbar  regions.  Marked 
forward  displacement  of  shoulder. 


FIG.     215. — Round     shoulders.        Kyphosis 
involves  whole  spine.      (Round  back.) 


scapulae  are  unduly  prominent  behind  and  may  be  noticed  through 
the  clothing  in  severe  cases,  and  the  whole  shoulder-joint  seems  to 
be  forward  of  its  normal  position;  the  chest  is  narrow  and  flattened, 
and  the  expansion  deficient.  The  lumbar  spine  may  present  an  in- 
creased forward  curvature,  so  that  the  patient  stands  with  an  abnor- 
mally hollow  back  (round  hollow  back),  or  the  lumbar  spine  may  be 
involved  in  the  backward  curve  and  the  lumbar  curve  diminished  or 


OTHER  DEFORMITIES  OF  THE  SPINE  AND  THORAX    245 

lost  (round  back).  The  patient's  trunk  swings  back  and  the  abdomen 
is  thrust  forward.  Some  degree  of  flat-foot  is  likely  to  coexist,  and 
beginning  lateral  curvature  accompanies  many  of  the  cases. 

With  the  persistence  of  the  attitude  of  round  shoulders  the  mus- 
cles   and    ligaments    in    front    of    the    shoulders    become    shortened 


FIG.  216.  — Round  Shoulders  with  Forward  Displace- 
ment of  Scapulas.     Back  comparatively  flat. 


FIG.  217.— Round  Shoulders    with 
Increased  Lumbar  Lordosis. 


and  those  at  the  back  stretched.  If  the  arms  are  carried  to 
a  vertical  position  above  the  head,  it  is  generally  done  by  arching 
the  spine  forward  in  the  lumbar  region,  which  is  made  necessary  by 
the  contraction  of  the  muscles  connecting  the  arms  and  upper  chest, 
such  as  the  pectoral  muscles.  Pain  may  occasionally  be  present  in 
nervous  children,  especially  girls. 

The  attitude  may  be  partially  corrected  temporarily  by  the  volun- 
tary muscular  effort  of  the  patient,  but  the  faulty  attitude  will  be 
again  assumed  almost  immediately,  as  the  muscles  are  unable  to  main- 
tain the  corrected  position. 


246 


ORTHOPEDIC  SURGERY 


Prognosis. — The  prognosis  without  treatment  is  not  good  in  pro- 
nounced cases,  so  far  as  recovery  from  the  deformity  is  concerned, 
and  it  may  be  carried  over  into  adult  life  practically  unchanged.  With 
proper  treatment  recovery  is  to  be  expected. 

Treatment. — In  the  treatment  of  round  shoulders  the  patient 
should  be  put  in  the  most  favorable  surroundings  possible.  Incorrect 


FIG.  218. — Sitting    Position    in    Marked    Round    Shoulders.      The    spine    is    flexible    and    can    be 
straightened   by   muscular   effort. 


attitudes  at  school  and  at  home  should  be  corrected  so  far  as  possible. 
Errors  in  vision  are  to  be  investigated  and  remedied  if  they  exist. 
Undue  fatigue  and  a  very  long  active  day  are  to  be  avoided. 

Round  garters  should  be  worn,  and  the  stockings  should  not  be 
fastened  to  the  waist.  The  trousers  and  skirts  should,  if  possible,  be 
supported  by  a  belt,  and  the  waist  to  which  the  clothes  are  ordinarily 
fastened  should  be  relieved  of  as  much  weight  as  possible. 

GYMNASTICS. — The  gymnastic  treatment  of  round  shoulders  con- 
sists in  stretching  the  contracted  tissues  and  in  drilling  the  child  in 


OTHER  DEFORMITIES  OF  THE  SPINE  AND  THORAX   247 

the  maintenance  of  a  correct  position.  The  stretching  can  usually  be 
accomplished  by  simple  measures.  Suitable  exercises  for  this  purpose 
are  within  the  range  of  any  good  gymnastic  teacher  and  should  be 
done  at  first  daily.  In  general  they  should  consist  of  the  "  setting  up 


FIG.  219. — Deformity  of  Shoulders  due  to  the  Presence  of  Cervical   Ribs.      (Dr.   C.   F.   Painter.) 

drill  "  of  the  gymnasium  and  the  military  recruit,  and  must  be  done 
with  force  and  precision. 

The  restoration  of  backward  flexibility  to  the  dorsal  spine  and 
shoulders  before  giving  corrective  work  is  essential. 

The  use  of  a  greater  degree  of  force  is  sometimes  necessary  to 
accomplish  the  desired  stretching.  This  may  be  accomplished  by  the 
application  of  plaster  jackets  applied  to  the  spine  with  the  dorsal 
region  hyperextended,  and  such  jackets  should  include  the  shoulders, 
which  are  pulled  backward  during  the  application  of  the  jacket.  As 
soon  as  flexibility  is  restored,  postural  gymnastic  work  of  the  type 
described  above  should  follow. 


248 


ORTHOPEDIC  SURGERY 


APPARATUS. — In  cases  of  marked  flexible  round  shoulders,  when 
the  children  are  unable  to  maintain  for  any  length  of  time  a  cor- 
rected position,  some  mechanical  assistance  to  the  extensor  muscles 
may  be  needed.  A  useful  brace  consists  of  a  posterior  horizontal 


FIG.   220. — Schulthcss'    Apparatus    for    Correction    of    Round    Shoulders.       (Schulthess.) 

pelvic  band,  grasping  the  pelvis  at  the  level  of  the  anterior  superior 
spines.  From  this  run  up,  at  a  distance  of  one  inch  or  less  from  the 
spinous  processes,  two  tempered  steel  uprights,  which  are  turned  out 
on  the  flat  at  their  upper  ends  and  terminate  just  below  the  root  of 
the  neck  well  toward  the  axillary  line,  where  they  are  furnished  with 
axillary  straps,  which  run  through  the  arm-pit  and  fasten  to  a 
transverse  crossbar  on  the  brace.  This  brace  is  furnished  \vith  an 
abdominal  band,  which  runs  from  the  upright  around  the  abdomen, 
to  assist  in  the  maintenance  of  the  correct  position. 

Treatment  by  braces  should  be  supplementary  to  gymnastic  treat- 
ment, and  only  used  when  the  latter  fails  to  yield  results. 

Static  Kyphosis  from  Occupation. — This  type  of  deformity  occurs 
in  adults  and  in  children.  In  adults  it  is  either  the  result  of  a  condition 
acquired  in  childhood  carried  over  into  adult  life,  or  it  is  acquired 
by  some  habitual  position  connected  with  the  occupation  of  the  indi- 


OTHER  DEFORMITIES  OF  THE  SPINE  AND  THORAX    249 

vidual.  It  is  seen  in  workmen  who  carry  heavy  loads  upon  their 
shoulders,  in  tailors  who  sit  cross-legged  with  the  spine  bent,  cobblers 
who  bend  over  their  work,  clerks  who  sit  continually  bent  over  a 


FIG.  221. — Apparatus   for   Stretching  of   Round    Shoulders. 


desk,  and  in  men  performing  heavy  work,  such  as  blacksmiths, 
who  work  continually  bending  over  a  bench  or  an  anvil.  The 
exaggerated  curve  of  the  dorsal  spine  acquired  by  children  who  bend 
over  their  desks  at  school  is  to  be  classed  in  a  measure  as  an  occupa- 
tion curvature. 

Kyphosis  may  also  occur  in  (2)  Pott's  disease,  (3)  spondylitis  de- 
formans,  (4)  scoliosis,  (5)  osteomalacia,  (6)  rickets,  (7)  ostitis 
deformans,  (8)  paralysis  of  the  back  muscles,  (9)  old  age,  acro- 
megaly,  and  secondary  osteoarthropathy. 

LORDOSIS. 

Lordosis  is  the  name  applied  to  the  increase  of  the  physiological 
forward  curve  in  the  lumbar  region.  The  amount  of  this  curve,  of 
course,  varies  in  normal  individuals  from  those  who  have  a  very  flat 


ORTHOPEDIC  SURGERY 


back  in  the  lumbar  region  to  those  who  have  a  very  markedly  hollow 
back.    The  various  conditions  in  which  lorclosis  exists  are  as  follows : 

1.  Lordosis  often  exists  in  connection  with  the  kyphosis  of  the 
dorsal  spine  spoken  of  in  connection  with  round  shoulders  as  round 
hollow  back. 

2.  Lordosis  also  exists  in  pregnant  women  and  often  in  persons 
with  large  abdomens. 

3.  Increased  lumbar  curve  may  exist  as  the  result  of  training  in 
professional  gymnasts,  especially  in  backward  contortionists. 


FIG.   222. — Patient  with   Round   Shoulders 
Before  Stretching. 


FIG.     223. — Patient     One     Month     Later 
After   Treatment   by   Stretching. 


4.  In  conditions  in  which  the  abdominal  or  the  back  muscles  are 
paralyzed,  the  attitude  of  lordosis  may  be  the  result  of  an  attempt  to 
balance  the  weight  of  the  upper  part  of  the  body  without  bringing 
a  strain  upon  the  muscles. 

5.  In  Pott's  disease  of  the  lumbar  region  apparent  lordosis  may  be 
one  of  the  first  symptoms  to  be  noticed. 

6.  In  cases  of  double  congenital  dislocation  of  the  hip  lordosis  gen- 
erally exists. 

7.  Lordosis  exists  in  many  cases  of  severe  rickets. 

8.  In   hip   disease,    with    flexion   deformity,    lordosis    is   present. 


OTHER  DEFORMITIES  OF  THE  SF] 

BE/3W 

Contraction  of  the  hip  in  flexion,   for  any  reason,   as  in  infantile 
paralysis,  causes  lordosis. 

9.  Lordosis  may  exist  in  coxa  vara  and  in  congenital  dislocation 
of  the  hip. 

10.  In  spondylolisthesis  lordosis  is  very  marked. 

Treatment. — The  treatment  of  these  curves  is  necessarily  de- 
pendent upon  the  causative  conditions  and  attendant  circumstances. 

SPONDYLOLISTHESIS. 

The  name  spondylolisthesis  refers  to  a  forward  subluxation  of 
the  body  of  one  of  the  lower  lumbar  vertebrae,  with  the  exception  of 
one  recorded  case  in  which  the  upper  part  of  the  sacrum  was  displaced 
forward. 

Pathology. — The  essential  part  of  the  condition  seems  to  be  the 

slipping  forward  of  one  of  the  lower 
lumbar  vertebral  bodies,  while  the  ver- 
tebral arches  remain  practically  in 
place.  This  implies,  of  course,  an  in- 
crease in  the  distance  between  the  body 
and  the  spinous  process  of  such  a  ver- 
tebra. The  commonest  form  of  the 
displacement  is  sublnxation  of  the  fifth 
lumbar  vertebra  in  relation  to  the  sa- 
crum. The  displacement  may  be  slight 
or  extreme. 

Etiology. — Spondylolisthesis  is  re- 
corded as  affecting  women  more  fre- 
quently than  men.  It  occurs  almost 
always  at  puberty  or  in  young  adult 
life,  and  the  majority  of  all  cases  give 
the  account  of  a  severe  traumatism,  oc- 
curring most  often  during  childhood  or 
near  puberty.  The  deformity  may  fol- 
low immediately  upon  the  accident,  or  it  may  develop  in  after  years. 
In  some  cases  no  assignable  cause  can  be  found. 

Symptoms. — There  is  a  sharp  increase  in  the  lower  lumbar  curve  in 
even  the  mildest  cases,  and  the  spine  curves  forward  sharply  from 
the  sacrum,  which  gives  undue  backward  prominence  to  the  crest  of 
the  ilium  and  the  buttocks.  The  appearance  at  first  glance  is  the 
same  as  that  in  cases  of  double  congenital  dislocation  of  the  hip. 
Lateral  deviation  of  the  spine  may  be  present.  With  this  lordosis 


FIG.  224. — Breslau  Specimen.  In- 
stance of  slight  forward  displace- 
ment of  the  fourth  lumbar  vertebra. 
(Neugebauer.) 


252  ORTHOPEDIC  SURGERY 

goes  a  diminution  of  the  obliquity  of  the  pelvis,  which  causes  flexion 
of  the  thighs.     Vaginal  examination  shows,  of  course,  a  prominence 


FIG.  225.  — Sponciylolisthesis  Due  to  \'ertebral  Disease.     (Dr.  Harvey  Cushing.) 


high  up  on  the  posterior  wall  of  the  pelvis.  The  truiiK  is  shortened  in 
relation  to  the  legs  on  inspection.  The  affection  is  not  one  character- 
ized by  excessive  pain. 

Treatment. — The  most  successful  treatment  consists  in  fixation  of 
the  lower  spine  by  a  jacket  or  brace  until  the  fracture,  if  such  has 
occurred,  has  united  and  the  products  of  the  injury  have  been  ab- 
sorbed; or,  if  heavy  weight-bearing  has  been  the  cause,  until  the 
stretched  and  weakened  tissues  have  resumed  as  normal  a  position 
as  possible.  In  cases  of  great  deformity  it  would  seem  as  if  a  support 
must  be  permanent. 

DEFORMITIES    OF   THE   THORAX. 

Pigeon  Breast  (chicken  breast,  Hiihnerbrust,  pectus  carinatum  or 
gallinatum,  poitrine  en  carene,  poitrine  de  pigeon,  etc.)  is  a  deformity 
more  or  less  common  in  children,  characterized  by  a  prominence  of  the 
sternum  and  cartilages  of  the  ribs  and  accompanied  by  an  increase  in 
the  antero-posterior  diameter  of  the  chest  and  a  diminution  in  the 
lateral.  The  deformity  is  generally  most  marked  in  the  median  line, 
but  in  many  cases  the  prominence  affects  chiefly  the  ribs  of  one  side, 
making  a  unilateral  prominence  on  one  side  of  the  sternum.  It  is 


OTHER  DEFORMITIES  OF  THE  SPINE  AND  THORAX    253 

due  to  rickets  and  is  associated  often  with  nasal  or  pharyngeal  ob- 
struction in  growing  children.  It  is  also  seen  in  a  marked  degree  in 
dorsal  Pott's  disease,  in  which  it  is  due  to  the  sinking  forward  of  the 
upper  dorsal  spine,  carrying  with  it  the  ribs.  In  slight  cases  the  de- 


FIG.  226. — Traumatic    Spondylolisthesis 
in  a  Young  Man  of  Eighteen. 


FIG.  227. — Funnel  Chest.      (J.  S.   Stone.) 


formity  is  probably  outgrown  spontaneously,  but  in  the  severer  cases 
it  may  last  into  adult  life. 

The  treatment  consists  in  children  in  a  combination  of  gymnastic 
and  respiratory  exercises  to  expand  and  develop  the  lateral  parts  of 
the  chest. 

Funnel  Chest  (funnel  breast,  Trichterbrust,  pectus  excavatum, 
thorax-en-entonnoir)  is  a  name  applied  to  a  deformity  in  which  the 
sternum  and  costal  cartilages  are  depressed  below  their  normal  level. 
The  deformity  is  as  a  rule  asymmetrical,  and  in  its  lighter  degrees  is 


254 


ORTHOPEDIC  SURGERY 


not  uncommon.  But  little  is  known  of  the  cause  of  the  affection;  in 
many  cases  it  apparently  is  congenital.  The  treatment  for  this  should 
consist  in  gymnastic  exercises,  especially  those  expanding  the  chest 
and  developing  the  muscles,  increasing  chest  expansion;  and  in  the 
severer  cases  the  temporary  use  of  light  braces,  checking  faulty 
attitudes. 

Congenital  Deformities. — Other  deformities  of  the  thorax  of  con- 
genital origin  need  only  to  be  mentioned.     Among  these  are  absence 


FIG.  228. — Congenital  Elevation  of  the  Scapula. 

or  a  defective  formation  of  the  ribs,  a  condition  generally  associated 
with  lateral  curvature  of  the  spine,  the  presence  of  cervical  ribs,  and 
anomalies  or  absence  of  the  pectoral  and  other  muscles.  Defective 
formation  or  absence  of  the  clavicle  has  been  reported,  and  malforma- 
tion of  the  scapula  is  sometimes  seen. 

Congenital  Elevation  of  the  Scapula  (Sprengel's  deformity,  ange- 
borene  Hochstand  des  Schulterblattes). — This  condition  is  a  some- 
what unusual  congenital  deformity,  in  which  one  scapula  is  raised  in 


OTHER  DEFORMITIES  OF  THE  SPINE  AND  THORAX    255 

its  relation  to  the  thorax  and  clavicle  and  also  to  the  opposite  scapula. 
The  scapula  is  not  only  raised,  but  generally  so  rotated  that  its  upper 
angle  approaches  the  spine.  Scoliosis  exists  in  connection  with  it, 
in  the  majority  of  cases,  and  in  some  cases  torticollis  and  asymmetry 
of  the  face  and  skull  have  been  noted ;  the  affection  is  rarely  bilateral. 
One  or  more  of  the  scapular  muscles  may  be  absent  and  bony  anomalies 
are  frequent,  and  in  the  majority  of  cases  some  congenital  defect 
is  present  elsewhere  in  the  body.  In  one  class  of  cases  a  bridge  of 
bone  connects  the  scapula  and  the  vertebral  column;  in  another  class 
there  is  a  long  piece  of  bone  projecting  upward  from  the  superior 
border  of  the  scapula,  but  not  articulating  with  or  attached  to  the 
vertebrae.  In  other  cases  there  is  no  bony  outgrowth  and  no  deficiency 
of  muscles.  In  some  cases  the  projecting  upper  border  of  the  scapula 
is  so  noticeable  in  its  elevated  position  that  it  is  mistaken  for  an 
exostosis.  The  symptoms  are  found  in  the  asymmetry  of  the  shoul- 
ders, the  secondary  changes  in  the  spine,  and  often  an  inability  to 
abduct  the  affected  arm  to  its  full  extent;  but  the  cases  are  evidently 
to  be  classed  with  other  congenital  malformations. 

The  affection  is  in  all  probability  due  to  a  congenital  survival  of 
the  foetal  condition,  by  which  the  normal  descent  of  the  scapula  from 
the  early  high  position  in  the  early  stage  is  arrested. 

In  cases  seen  during  childhood  extensive  division  of  the  shortened 
muscles  holding  the  scapula  in  its  abnormal  position  is  to  be  advised, 
and  the  removal  of  any  bony  bridge  or  projection,  and  in  resistant 
cases  resection  of  as  much  of  the  upper  border  of  the  scapula  as  may 
be  necessary.  Improvement  may  thus  be  obtained.  In  older  cases  no 
operative  treatment  is  advisable.  The  cases  can  be  benefited  by  per- 
sistent gymnastic  treatment. 


CHAPTER  XIII. 

TORTICOLLIS. 

DEFINITION. 

THE  name  torticollis  is  given  to  that  distortion  of  the  head  which 
causes  it  to  be  held  awry,  and  this  condition  is  either  constant  or  inter- 
mittent. The  other  names  by  which  this  affection  is  known  are  wry- 
neck, caput  obstipnm,  con  tortu,  Schiefhals. 

ETIOLOGY. 

Torticollis  may  be  (I)  congenital  or  (II)  acquired. 

I.  CONGENITAL  TORTICOLLIS. 

(a)  It  may  exist  in  connection  with  other  deformities,  such  as 
club-foot  and  similar  malformations.     In  these  cases  it  seems  proper 
to  attribute  its  existence  to  those  intra-uterine  conditions  causing  other 
deformities.     Other  intra-uterine  conditions  to  which  it  may  be  at- 
tributed are : 

(b)  Abnormal  pressure  of  the  uterus. 

(c)  Amniotic  adhesions. 

(d)  Inflammation  of  the  muscles  seems  to  be  proved  by  the  patho- 
logical findings  in  certain  cases  and  must  be  mentioned. 

(f)  Arrest  of  the  development  of  the  muscles  due  to  an  affection 
of  the  nerves  or  nerve  centres  is  a  cause  often  advanced  to  account 
for  torticollis. 

(/)  Rupture  of  the  sterno-mastoid  muscle  occurring  at  birth  has 
been  mentioned  as  a  cause  of  torticollis,  and  undoubted  cases  have 
been  observed  where  torticollis  has  followed  partial  rupture  of  the 
sterno-mastoid  at  childbirth.  Torticollis,  however,  has  not  followed 
the  hrematomata  from  rupture  of  the  sterno-mastoid  at  birth  in  a 
number  of  cases  carefully  watched  by  several  observers. 

(g)  Imperfections  in  the  atlas  and  cervical  vertebrae  have  in  some 
reported  cases  been  the  cause  of  congenital  torticollis. 

256 


TORTICOLLIS 


257 


II.  ACQUIRED  TORTICOLLIS. 

As  the  causes  of  this  form  of  the  affection  may  be  mentioned : 
Cicatricial  contraction  of  the  skin  or  deeper  tissues,  traumatism  to 
the  neck  and  head,  dislocation  of  the  upper  cervical  vertebne,  inflam- 
ination    of    the    muscle     ("  rheu- 
matic "     torticollis     or     acute     or 
chronic  myositis),  reflex  irritation 
of   the   muscles    in    caries   of   the 
spine. 

Torticollis  may  also  be  seen  in 
inflammation  of  the  cervical  lymph 
nodes  or  with  deep  cervical  ab- 
scesses, retropharyngeal  abscesses, 
inflammations  of  the  ear,  parotitis, 
adenoid  vegetations  in  the  naso- 
pharynx, tumors  of  the  neck,  and 
cerebral  lesions.  Neuralgia  of  the 
spinal  accessory  or  cervico-brachial 
nerves  may  be  accompanied  by  tor- 
ticollis. Other  causes  of  acquired 
torticollis  are : 

Difference  in  the  plane  or 
power  of  vision  of  the  eyes,  lateral 
curvature,  voluntary  habit  (physi- 
ological torticollis),  occupations  in 
which  the  overuse  of  one  sterno- 

mastoid  muscle  is  necessary,  injury  to  the  nerve  centres  at  the  time  of 
birth,  paralysis  of  the  spinal  accessory  nerve  from  such  causes  as 
rheumatism  or  trauma  as  well  as  anterior  poliomyelitis  and  the  muscu- 
lar dystrophies. 


FIG.  229. — Torticollis    Showing    Contraction 
of  the   Right   Sterno-mastoid  Muscle. 


SPASMODIC  TORTICOLLIS. 

In  this  class  are  included  those  cases  which  arise  from  nerve  irrita- 
tion. This  form  may  be  central  and  occur  in  the  distribution  of  the 
spinal  accessory  nerve,  or  it  may  be  the  local  manifestation  of  a  more 
general  nervous  irritation  and  involve  several  groups  of  muscles.  In 
some  cases  of  the  spasmodic  form,  the  affection  is  closely  allied  to 
writers'  cramp,  spasmodic  tic  of  the  face,  etc.1 

iTraite  des  Tort.  Spasm.     Cruchet,  Paris,  1907. 


258 


ORTHOPEDIC  SURGERY 


PATHOLOGY. 


In  some  instances  of  congenital  torticollis  the  contracted  muscle 
appears  normal,  but  more  often  the  muscular  substance  is  replaced 
by  fibrous  tissue.  This  may  occur  in  small  patches  or  the  whole  mus- 
cle may  be  transformed  into  a  tendinous  band.  In  the  majority  of 


FIG.  230. — Torticollis  Due  to  Contraction  of  Right  Sterno-mastoid  Muscle. 

cases  of  fibrous  degeneration  of  the  muscle  it  is  adherent  to  the  sheath, 
and  in  some  instances  muscle  and  sheath  are  fused  m  one  fibrous 
band. 

The  changes  described  are  to  be  classed  as  fibrous  myositis,  and 
perimyositis  has  been  demonstrated  in  certain  cases.  Shortening  of 
the  muscle  on  the  affected  side  may  amount  to  several  centimetres. 

Secondary  changes  occur  in  long-continued  torticollis,  the  most 
marked  of  which  is  asymmetry  of  the  face.  It  may,  on  the  other  hand, 
be  present  in  birth  without  the  existence  of  torticollis.  This  asym- 
metry diminishes  if  the  deformity  is  corrected  early.  Asymmetry  of 
the  skull  may  also  be  found,  as  well  as  a  diminished  size  of  the  cerebral 
hemisphere  on  the  affected  side.  The  carotid  artery  of  the  affected 
side  has  been  in  certain  cases  found  smaller. 

This  asymmetry  of  the  face  may  also  occur  in  acquired  torticollis 
of  long  standing. 


TORTICOLLIS 


259 


Lateral  curvature  of  the  spine  will  result  from  long-continued 
torticollis,  and  a  difference  in  the  length  of  the  clavicles  has  been 
noted. 

SYMPTOMS. 

Congenital  Torticollis. — The  position  held  by  the  head  varies 
necessarily  with  the  muscles  affected.  When  the  sterno-cleido-mastoid 

of  one  side  is  shortened,  the  ear 
of  the  affected  side  is  brought 
near  to  the  sternum  and  the 
face  slightly  rotated  to  the  oppo- 
site side.  If  the  trapezius  or  pos- 
terior muscles  are  also  affected, 
the  head  will  also  be  drawn  back, 
the  chin  elevated  above  its  normal 
level,  and  the  features  on  the  side 
of  the  spasm  drawn  below  those 
on  the  opposite  side.  In  addition 
to  these  muscles,  the  platysma  and 
deep  muscles  of  the  neck  are 
sometimes  affected,  and  modify 
more  or  less  the  position  of  the 
head.  The  attitude  is  sometimes 
so  peculiar  as  to  render  it  diffi- 
cult to  determine  exactly  what 
muscles  are  affected.  On  palpa- 
tion certain  muscles  will  be  found 
to  be  hard  to  the  touch  and  others 
flaccid.  Rotation  of  the  head  is 
free  up  to  a  certain  limit,  varying 

in  extent.     It  is  not  possible  to  move  the  head  in  a  direction  against 
the  contraction. 

Acquired  Torticollis. — In  the  acute  form  the  history  is  that  of  an 
acute  muscular  "  rheumatism,"  an  acute  glandular  inflammation,  a 
traumatism,  etc.,  with  sudden  onset  with  a  great  deal  of  pain  on 
movement  of  the  head,  and  the  head  is  held  to  one  side.  The  acute 
stage,  however,  lasts  but  a  short  time,  and  the  position  assumed  by 
the  head  is  more  or  less  typical  and  is  described  above.  A  chronic 
form  may  develop  from  the  acute  form. 


FIG.  231. — Result  of  Open  Incision  One  Year 
after  Operation  in  a  Girl  of  Sixteen. 
Shows  also  the  unequal  development  of  the 
face. 


260  ORTHOPEDIC  SURGERY 

SPASMODIC  TORTICOLLIS. 

The  intermittent  form  of  torticollis  is  not  infrequent  and  occurs 
mostly  in  adults.  At  times  the  head  can  be  held  in  a  proper  position, 
but  locomotion  or  any  excitement  or  the  apprehension  of  being  ob- 
served may  produce  such  a  contraction  of  the  head  that  it  will  be 
twisted  violently  to  one  side  and  rotated  to  an  extreme  limit.  A 
slight  pressure  of  the  hand  steadying  the  head  will  ordinarily  correct 
it,  but  when  the  muscular  contraction  becomes  excited,  great  force 
is  required  to  hold  the  head  in  place  in  some  cases.  In  certain  cases 
the  contraction  may  be  slow  and  steadily  increase  to  its  maximum. 
In  a  recumbent  position  the  contraction  does  not  ordinarily  take  place 
and  usually  disappears  during  sleep.  The  spasm  is  sometimes  tonic 
and  sometimes  clonic.  and  sometimes  pain  is  excited  by  the  muscular 
contraction.  It  is  usually  confined  to  the  muscles  of  one  side  or  to 
associated  groups  of  muscles  on  the  two  sides,  and  may  involve  the 
muscles  of  the  back.  Slight  twitchings  of  the  muscles  are  sometimes 
observed  for  some  time  previous  to  an  outbreak  of  the  spasmodic 
condition. 

DIAGNOSIS. 

There  is  no  difficulty  in  recognizing  the  deformity  of  congenital 
wry-neck.  The  head  is  twisted  to  one  side,  the  chin  being  to  the  right 
or  left  of  the  sterno-clavicular  notch,  while  the  face  is  turned  to  one 
side  and  partly  upward.  The  shoulders  are  held  obliquely  to  the 
trunk  and  twisted,  in  order  to  bring  the  face  so  far  as  possible  in  a 
vertical  line.  Certain  of  the  muscles,  frequently  the  sterno-cleido- 
mastoid,  are  felt  hard  on  palpation ;  some  rotation  of  the  head  is 
possible,  but  perfectly  free  rotation  of  the  head  is  checked  by  the 
contracted  muscles. 

A  diagnosis  of  the  cause  and  situation  of  wry-neck  is  more  diffi- 
cult, as  well  as  an  attempt  to  distinguish  it  from  other  affections 
which  give  rise  to  this  malformation,  a  matter  which  is  of  great 
importance.  Such  affections  have  been  enumerated. 

The  diagnosis  between  anterior  and  posterior  torticollis  (or  torti- 
collis due  to  contraction  of  the  anterior  muscles,  chiefly  the  sterno- 
cleido-mastoid,  and  that  due  to  the  contraction  of  the  posterior  muscles, 
the  trapezius  and  splenius  capitis,  etc.),  is  to  be  based  on  palpation 
chiefly.  Palpation  also,  with  a  clinical  history  of  paralysis  and  the 
evidence  of  paralysis  elsewhere,  is  sufficient  usually  to  determine  the 
diagnosis  of  paralytic  torticollis. 


TORTICOLLIS 


261 


Torticollis  dependent  upon  enlarged  and  inflamed  glands  can 
usually  be  recognized  by  the  evidence  of  glandular  enlargement. 
There  is  ordinarily  little  difficulty  in  recognizing  the  common  acute 
wry-neck.  Its  course  is  acute,  the  deformity  appears  suddenly,  and 
it  is  usually  accompanied  by  pain.  Improvement  is  to  be  noticed  in 
a  comparatively  short  time. 

For  the  diagnosis  of  congenital  torticollis  from  that  due  to  Pott's 


FIG.  232. — Posterior   Torticollis    Before 
Forcible   Straightening. 


FIG.  233- — After  Operation. 


disease,  it  may  be  said  that  in  the  latter  there  is  greater  rigidity, 
which  involves  all  the  muscles  of  the  neck,  and  particularly  the  pos- 
terior groups.  The  pain  elicited  by  attempts  to  twist  the  head  is 
greater.  When  a  patient  with  cervical  Pott's  disease  attempts  to  lie 
down  or  turn  over  the  head  is  instinctively  steadied  with  the  hand, 
while  in  true  torticollis  this  is  not  a  symptom. 

PROGNOSIS. 

Congenital  forms  of  torticollis  and  the  common  acquired  form 
(associated  with  muscular  contraction  which  has  become  chronic  and 
developed  fibrous  muscular  degeneration)  demand  surgical  interven- 
tion. The  acute  idiopathic  wry-neck  due  to  muscular  inflammation 
runs  a  short  course  and  tends  naturally  to  recovery.  Torticollis  due 


262 


ORTHOPEDIC  SURGERY 


to  abscess  of  the  cervical  glands  terminates  with  the  complete  dis- 
charge of  the  abscess  as  a  rule. 

The  deformity  is  one  which  is  eminently  curable  by  surgical  inter- 
vention in  practically  all  cases  except  in  the  intermittent  form, 
which  is  dependent  upon  a  general  depressed  state  of  the  nervous 
system,  in  which  a  cure  cannot,  as  a  rule,  be  expected,  even  by  sur- 
gical interventi  n. 

TREATMENT. 

In  acute  torticollis  due  to  the  inflammation  of  the  muscles,  the 
treatment  is  largely  the  alleviation  of  the  symptoms.  This  is  best 


FIG.  234. — Torticollis  Brace.  Front    View. 


FIG.    235. — Torticollis    Brace    Applied, 
Back  View. 


accomplished  by  the  application  of  moist  heat,  rest  of  the  head,  and 
constitutional  treatment. 

Torticollis  due  to  cervical  Pott's  disease  is  treated  according  to 
the  principles  of  treatment  of  that  affection.  Torticollis  due  to  mus- 
cular contraction  secondary  to  cervical  abscesses  or  enlarged  glands  is 
corrected  by  the  proper  treatment  of  the  local  condition.  Torticollis 
clue  to  an  affection  of  the  eye  should  receive  proper  ocular  treatment. 


TORTICOLLIS 


263 


Congenital  Torticollis. — The  treatment  of  wry-neck  due  to  perma- 
nent muscular  contraction  is  either  purely  mechanical,  or  operative, 
or  mechanical  and  operative. 

MECHANICAL  TREATMENT. — Mechanical  treatment  without  the  aid 
of  operation  is  usually  unsuccessful,  except  in  the  lightest  cases,  in 
which  cases  massage  and  passive  manipulation  are  of  value  in  con- 
nection with  mechanical  treatment;  but  mechanical  treatment  is  in 
general  to  be  regarded  as  of  value  chiefly  in  retaining  the  correction 
obtained  by  operative  measures. 

OPERATIVE  TREATMENT. — In  the  usual  form  of  torticollis  the  con- 
tracted muscle,  the  sterno-mastoid,  is  easily  divided.  Division  is  made 
(i)  either  at  the  sternal  and  clavicular  insertion,  or  (2)  at  its  origin 
at  the  mastoid  process.  Subcutaneous  tenotomy  is  to  be  rejected  as 
dangerous. 

Division  at  the  Sterno-Cleido  Insertion. — An  incision  of  the  skin 
is  made  parallel  to  the  clavicle,  laying  bare  the  insertion  of  the  muscle. 

The  incision  should  be  sufficiently  long 
to  expose  the  whole  attachment,  as  it 
is  desirable  that  no  undivided  fibres  re- 
main. It  is  desirable  that  the  resulting 
scar  should  be  as  low  as  possible,  to  ac- 
complish which  the  skin  is  drawn  up- 
ward and  divided  on  the  clavicle,  after 
which  the  skin  gapes  sufficiently  to  per- 
mit the  division  of  the  muscular  attach- 
ments above  the  clavicle  if  the  head  is 
retracted,  which  will  also  serve  to  make 
prominent  the  contracted  muscles.  The 
tissues  to  be  divided  are  to  be  carefully 
freed  from  all  overlying  tissue  and  a 
director  passed  under  the  sternal  ten- 
don, care  being  taken  that  the  director 
is  passed  completely  under  and  not 
through  the  muscular  attachment.  It 
is  usually  necessary  that  both  the  cla- 
vicular and  sternal  attachments  of  the 
muscle  be  divided  to  prevent  any  possi- 
bility of  relapse.  With  ordinary  care 
there  is  no  danger  of  dividing  the 
vessels,  although  they  are  in  close  proximity. 

Mastoid  Division  of  the  Sterno-Cleido-Mastoid  Muscle. — A  di- 


FIG.   236.  —Torticollis  Brace. 


264  ORTHOPEDIC  SURGERY 

vision  of  the  sterno-mastoid  at  its  origin  from  the  mastoid  process 
has  been  advocated  on  the  ground  that  the  incision  is  away  from 
the  vessels  and  that  the  resulting  scar  is  in  a  less  noticeable  region. 
For  this  division  a  skin  incision  is  made  behind  the  ear  and  the  muscle 
divided  transversely  just  below  the  tip  of  the  mastoid  process,  the 
muscle  being  pulled  up  by  a  pointed,  curved  dissector.  The  muscular 
origin  is  much  thicker  than  the  clavicular  insertions  and  care  will  be 
needed  to  divide  the  muscle  thoroughly.  The  writers  have  been  in  the 
habit  of  using  the  clavicular  operation  with  satisfactory  results.  As 
the  results  are  excellent,  the  technique  is  simpler,  and  relapse  does  not 
occur  in  properly  treated  cases. 

After  the  operation  the  neck  and  chest  are  covered  with  sheet 
wadding  and  the  head  is  fixed  in  an  overcorrected  position  by  plaster 
bandages  applied  around  the  head,  shoulders,  and  thorax  at  or  a  day 
or  so  after  the  operation.  It  is  unnecessary  for  the  patient  to  remain 
in  bed  longer  than  a  few  days,  if  satisfactory  plaster  fixation  is 
furnished.  It  should  be  borne  in  mind  that  not  only  correction  but 
overcorrection  is  necessary  to  prevent  a  relapse,  which  will  follow 
to  a  greater  or  less  degree  unless  this  is  done. 

After  the  wound  is  entirely  healed  the  patient  should  wear,  for 
from  three  to  six  months,  a  retaining  appliance  holding  the  head 
in  an  overcorrected  position.  This  can  be  a  plaster  bandage,  a  leather 
moulded  on  a  plaster  form,  or  a  steel  appliance.  The  latter  is  as  fol- 
lows: A  stiff  wire  collar  passes  around  the  neck,  furnished  with 
a  plate  under  the  chin,  arranged  so  as  to  press  on  the  deflected  side 
of  the  chin.  Pressure  is  also  arranged  to  be  applied  to  the  inclined 
side  of  the  head  behind  the  ear.  The  wire  collar  is  attached  to  a 
ring  which  rests  upon  the  shoulder,  and  is  furnished  with  arms  which 
pass  down  the  back.  The  asymmetry  of  the  face  becomes  more  notice- 
able after  correction  than  it  was  in  the  deformed  position,  but  in 
children  disappears  gradually  if  the  corrected  position  is  retained. 

Posterior  Torticollis. — The  only  efficacious  treatment  of  this  form 
is  that  of  forcible  correction  without  tenotomy,  for  the  reason  that, 
as  a  rule,  the  muscles  are  too  deep  or  extensive  to  be  tenotomized. 
The  writers  have  divided  the  outer  bands  of  the  anterior  scalenus  and 
trapezius  by  open  incision  and  can  report  the  feasibility  of  the  pro- 
cedure. In  correcting  this  deformity  the  patient  should  be  thoroughly 
anaesthetized,  and  an  assistant  should  hold  the  shoulders  firmly,  while 
the  patient  should  be  so  placed  that  the  head  projects  beyond  the  end 
of  the  operating-table.  The  head  should  be  held  by  the  hands  of  the 
surgeon  and  rotated  in  all  directions,  considerable  force  being  used. 


TORTICOLLIS  265 

The  danger  of  fracturing  the  spine  is  in  such  cases  so  slight  as  to 
be  disregarded,  and  the  deformity  can  be  overcorrected.  After  the 
operation  the  head  should  be  fixed,  the  after-treatment  resembling  that 
of  the  ordinary  torticollis. 

Spasmodic  Torticollis. — This  form  of  wry-neck  (known  also  as 
intermittent)  is  resistant  to  treatment,  and  in  many  cases  cannot  be 


FIG.  237. — Plaster-of- Paris  Apparatus  Applied  after  Operation   for  Torticollis. 

relieved  by  any  means  known  to  us  at  present.  The  constitutional 
nature  of  the  affection  is  an  important  factor  to  be  considered.  The 
affection  may  be  considered  a  localized  chorea  or  a  disturbance  of 
the  proper  muscular  balance  of  the  muscles  holding  the  head.  Of  the 
constitutional  treatment  nothing  need  be  said,  further  than  that  the 
success  of  treatment  demands  the  removal  of  the  patient  from  all 
depressing  influences  and  the  elimination  of  sources  of  reflex  irrita- 
tion such  as  eye  strain,  etc.  The  surgical  treatment  consists  of 
measures  of  fixation,  muscular  rest,  muscular  development,  and 
operative  measures. 


266  ORTHOPEDIC  SURGERY 

TREATMENT  BY  REST  AND  FIXATION. — Treatment  by  absolute  rest 
of  all  muscles  sustaining  the  weight  of  the  head  should  be  tried.  This 
can  be  furnished  by  placing  the  patient  in  a  recumbent  position  with- 
out pillows  and  fixing  the  head  by  sand  bags  applied  at  each  side  of 
the  head.  A  plaster  bandage  can  be  applied  or  a  moulded  leather  sub- 
stitute holding  the  head,  shoulders,  and  trunk  firmly,  relieving  the 
muscles  from  any  weight-bearing  strain.  \Yith  this  the  patient  is 
relieved  of  the  restraint  of  recumbency.  Local  applications  can  be 
made  to  the  muscles  with  electricity  and  massage. 

TREATMENT  BY  MUSCULAR  TRAINING. — Great  benefit  may  follow 
carefully  directed  and  graded  exercises  directed  to  the  cultivation  of 
the  groups  of  muscles  which  tend  to  correct  the  malposition. 

TREATMENT  BY  OPERATIVE  MEASURES. — The  tedious  and  unsat- 
isfactory nature  of  conservative  treatment  suggests  the  employment 
of  operative  measures.  The  restoration  of  muscular  balance  by 
myotomy,  fasciotomy,  and  the  incidental  temporary  muscular  rest  is 
observed  in  the  surgical  treatment  of  muscular  spasm  in  spastic  paral- 
ysis, and  the  same  principles  can  be  applied  in  spasmodic  torticollis. 
The  muscles  involved  are  not  only  the  sterno-cleido-mastoid,  but  the 
various  muscles  in  the  back  of  the  neck.  Stretching,  division,  and 
excision  of  portions  of  the  nerves  supplying  these  muscles  have  been 
employed. 

The  nerves  to  be  divided  are  the  spinal  accessory  from  the  sterno- 
mastoid,  and  the  nerve  roots  of  the  deep  posterior  cervical  plexus. 

Extensive  division  of  practically  all  the  posterior  neck  muscles 
from  one  sterno-mastoid  around  to  the  other  has  been  practised.  But 
the  fact  remains  that  relapses  after  all  operations  may  occur,  and 
that  both  mechanical  and  operative  treatment  of  the  affection  are  at 
present  discouraging  and  unsatisfactory. 


CHAPTER  XIV. 

INFANTILE  PARALYSIS. 

ANTERIOR  poliomyelitis,  or  infantile  paralysis,  or  polio-myelo- 
encephalitis  is  an  acute  infection  which  attacks  chiefly  children.  It 
comes  on  with  a  sudden  onset  and  deprives  certain  muscles  and  often 
an  entire  limb  of  muscular  power,  and  the  parts  affected  undergo 
rapid  atrophy.  The  paralysis  is  a  purely  motor  one. 

ETIOLOGY. 

The  disease  may  occur  in  epidemics,  but  is  also  seemingly  sporadic, 
is  probably  contagious,  and  is  a  disease  affecting  chiefly  children, 
and  reaching  its  highest  incidence  in  the  late  summer.  The  pathology, 


FIG.  238.. — Anterior    Poliomyelitis.       Chronic    Stage;    Section    through    Sixth    Cervical    Segment; 
Dimunition  of  Anterior  Gray  Matter  and  of  Entire  Half  of  Right  Side.      (Sachs.) 


etiology,  and  symptomatology  of  the  disease  are  described  in  medical 
text-books.  In  this  place  will  be  considered  only  the  surgical  aspects 
of  the  affection.  From  this  point  of  view  the  disease  is  to  be  regarded 
pathologically  as  a  hemorrhagic  myelitis,  with  its  chief  destruction  sit- 
uated in  the  cells  of  the  anterior  cornua  of  the  cord  with  the  conse- 
quent loss  of  power  in  the  affiliated  muscles.  These  may  show 
parenchymatous  or  interstitial  changes  late  in  the  affection.  In  the 
severest  cases  the  muscles  become  mere  bundles  of  interstitial  tissue. 

267 


268  ORTHOPEDIC  SURGERY 

SYMPTOMS. 

For  surgical  purposes  the  clinical  history  of  the  disease  falls  into 
three  stages  : 

(a)  The  onset,  to  which  stage  belong  the  acute  febrile  symptoms 
and  the  development  of  paralysis. 

(b)  The  stage  of  convalescence,  which  begins  at  the  time  of  the 
full  development  of  the  paralysis,  and  is  followed  by  a  brief  stationary 
period,  and  finally  rapid  and  then  slower  improvement  until  a  station- 
ary period  is  readied. 

(c)  The  stage  of  deformity,  in  which  wasting  of  the  affected  limb 
is  present,  and  static,  paralytic,  and  contraction  deformities  have  super- 
vened. 

No  arbitrary  subdivision  of  the  classes  of  symptoms  can  be  made, 
because  in  reality  the  stages  run  into  each  other. 

Infantile  paralysis  is  oftenest  ushered  in  by  a  mild  or  severe  febrile 
attack.  The  elevation  of  temperature  is  not  excessive,  commonly 
from  100°  to  102°  F.,  sometimes  even  104°.  With  this  fever  are  apt 
to  be  associated  vomiting,  convulsions,  giddiness,  or  other  cerebral 
disturbance,  sometimes  even  delirium.  The  majority  of  children  com- 
plain of  pain  and  tenderness  in  the  back  and  limbs.  There  is,  as  a 
rule,  no  warning  of  the  attack.  The  feverish  attack  at  the  onset  is 
generally  followed  by  paralysis  in  from  one  to  four  days,  although 
the  interval  may  be  longer.  In  certain  cases  all  feverish  and  other 
symptoms  are  absent  at  the  onset,  and  the  child  is  suddenly  discov- 
ered to  be  paralyzed  in  one  or  more  limbs. 

During  the  first  few  days  there  may  be  paralysis  of  the  bladder 
with  retention  or  incontinence  of  urine. 

The  paralysis  itself  very  quickly  becomes  manifest,  and  having 
reached  its  maximum,  remains  stationary  for  a  short  time,  when 
improvement  begins.  In  some  cases  (probably  about  25  per  cent) 
improvement  begins  immediately  after  the  attack  and  proceeds  to 
complete  recovery.  The  more  common  course  is  for  the  paralysis 
to  remain  nearly  stationary  for  a  time  varying  from  two  to  six  weeks, 
and  then  to  improve,  at  first  rapidly  and  then  more  slowly,  for  three 
•or  four  months.  After  six  months  have  passed,  further  spontaneous 
improvement  is  unusual. 

Vascular  changes  later  become  marked,  and  the  temperature  of  the 
limb  is  much  lower  than  that  of  the  other.  The  limb  is  generally 
bluish,  with  a  superficial  stagnation  of  the  blood,  and  when  the  blood 
is  pressed  out  of  the  surface  capillaries  by  the  finger  it  returns  slowly. 


INFANTILE  PARALYSIS 


269 


On  account  of  this  vascular  sluggishness  ulcers  may  form  later  on 
which  are  slow  to  heal  and  very  painful.  The  limb  even  very  early 
loses  its  normal  appearance,  and  the  flaccid  undeveloped  look  of  the 
foot  or  hand  is  most  noticeable. 

Atrophy  of  the  affected  muscles  begins  to  be  perceptible  very  soon 
after  the  onset  of  the  paralysis.    Muscles  seriously  affected  are  toneless 


FIG.  239. — Paralysis  of  the  Left  Leg,  with  Talipes  Equinus  and  Contraction  of  the  Fascia  at 
the  Anterior  and  Outer  Aspect  of  the  Thigh  with  Involvement  of  the  Internal  Rotators  and 
Abductors  of  the  Leg,  Resulting  in  a  Position  of  Abduction  and  Eversion. 

and  flaccid  from  the  first,  and  in  the  late  stages  of  wasting  scarcely 
any  volume  of  muscles  seems  left  when  the  limb  is  grasped  with  the 
hand. 

The  paralysis  is  a  purely  motor  one,  and  in  the  early  stages 
sensitiveness  is  generally  present;  tingling  and  formication  may 
also  be  present.  The  reflexes  are  abolished  in  the  affected 


2/o  ORTHOPEDIC  SURGERY 

limb  if  the  paralyzed  muscles  are  those  involved  in  the  reflex 
area. 

Often  after  an  attack  the  paralysis  may  seem  to  be  general, 
but  the  probabilities  are  that  after  improving  in  general,  the  loss  of 
power  will  eventually  be  localized  in  one  limb,  and  that  if  one  limb 
originally  is  paralyzed  the  likelihood  is  very  great  that  a  certain 
amount  of  power  will  be  regained,  leaving  only  certain  groups  of 
muscles  permanently  paralyzed. 

The  muscles  of  the  back  may  be  paralyzed  and  the  patient  be 
unable  to  sit  erect,  or  lateral  curvature  may  result — a  state  of  affairs 
often  made  worse  by  allowing  the  patient  to  sit  erect  while  the  muscles 
are  still  weak.  The  diaphragm  is  occasionally  paralyzed.  In  those 
cases  of  paralysis  of  the  abdominal  muscles,  the  patient  leans  back 
to  a  very  marked  degree,  missing  the  restraining  action  of  the  ab- 
dominal muscles.  There  are,  finally,  cases  of  universal  paralysis  in 
which  death  soon  takes  place  from  interference  with  respiration. 

Deformities. — The  deformities  which  follow  after  infantile  paraly- 
sis are  late  events  in  the  history  of  the  disease,  but  develop  at  times  a 
few  weeks  after  the  attack.  They  are,  as  a  rule,  progressive  in  their 
character.  The  deformities  fall  into  two  chief  classes :  ( i )  deformities 
due  to  trophic  changes,  such  as  bone  shortening,  etc.;  (2)  deformities 
due  to  muscular  paralysis. 

1 i )  The  first  class  is  comparatively  unimportant ;  shortening  of 
the  paralyzed  arm  or  leg  may  take  place  with  atrophy  of  the  bone 
in  every  direction.     Shortening  of  the  arm  is  comparatively  unimpor- 
tant in  itself,  but  shortening  of  the  leg  may  induce  lateral  curvature 
of  the  spine  from  the  necessarily  tilted  position  of  the  pelvis  due  to 
the  unequal  length  of  the  legs. 

(2)  The  deformities  of  the  second  class,  which  are  the  result  of 
muscular  paralysis,  are  manifold  and  form  the  great  bulk  of  the  cases 
of  deformity  in  anterior  poliomyelitis.     As  a  rule  they  do  not  appear 
earlier  than  two  or  three  months  after  the  onset  and  more  commonly 
not  for  many  months. 

For  clinical  consideration  they  fall  into  two  groups :  deformities 
caused  by  contraction,  and  deformities  due  to  laxity  of  the  muscles 
and  ligaments. 

A  word  should  be  said  in  regard  to  the  reason  of  the  more  severe 
affection  of  the  anterior  leg  and  thigh  muscles  than  of  the  posterior 
muscles  in  nearly  all  cases.  After  a  paralysis  of  the  leg,  the  limb 
lies  flaccid  and  nearly  powerless,  the  toes  drop,  and,  if  the  sitting 
posture  is  assumed,  the  knees  flex  and  the  legs  hang  heavily  dowrn. 


INFANTILE  PARALYSIS  271 

As  a  result  of  this,  the  anterior  muscles  are  always  pulled  upon  and 
slightly  stretched,  while  the  posterior  ones  are  lax.  If  all  the  muscles 
are  equally  affected,  this  very  factor  may  be  enough  to  make  a  great 
difference  in  the  ultimate  usefulness  of  the  two  groups.  Stretched 
muscles  are  notoriously  at  a  disadvantage,  so  far  as  recovery  goes,  in 
any  diseased  condition,  and  muscles  at  rest  are  much  more  favorably 


FIG.  240. — Paralysis  of  the  Back  Muscles,  Causing  Saddle-back  Deformity. 

situated.  So  that  this  very  point  may  determine  in  a  measure  the 
relative  amount  of  recovery  in  the  two  groups. 

Moreover,  muscular  contraction  and  consequent  deformity  occur 
in  cases  in  which  a  muscle  has  been  allowed  to  remain  for  a  long 
time  in  a  shortened  or  stretched  condition.  For  this  reason  it  is  highly 
important  to  support  and  restrain  the  affected  limb  in  a  normal  posi- 
tion (the  foot  at  a  right  angle  to  the  leg,  etc.). 

The  most  important  deformities  from  infantile  paralysis  which 
come  to  the  orthopedic  surgeon  for  treatment  are  those  of  the  lower 
extremity.  Considered  in  detail,  it  is  best  to  begin  with  deformities 
at  the  hip-joint  and  then  to  pass  on  to  the  consideration  of  knee-joint 
deformities  and  distortions  of  the  foot. 

Deformities  of  the  Leg. — Paralysis  may  be  complete  and  a  flail- 
like  leg  be  the  result,  with  wasted  muscles  and  loose,  distorted  joints, 


272 


ORTHOPEDIC  SURGERY 

Such  a  limb  is  spoken  of  as 


incapable  of  motion  or  bearing  weight. 
'*  jambe  de  Polichinelle." 

But  more  commonly  the  paralysis  is  partial  rather  than  complete. 
The  muscles  of  the  thigh  commonly  affected  are  the  internal  and  ante- 
rior groups.  This  constitutes  a  serious  combination  and  renders 
walking  difficult ;  not  only  is  the  leg  abducted  with  a  tendency  to 


FIG.  241. — Severe    Double    Paralysis    with    Marked    Knock-knee    and    Distortion    of    Feet.      This 

patient  was  unable  to  walk. 

eversion,  but  the  extensor  thigh  muscles  cannot  hold  the  knee  rigid 
as  is  necessary  in  walking,  the  leg  giving  way  whenever  weight  is  put 
upon  it.  The  glutei  are  generally  implicated  in  this  paralysis,  and 
the  contraction  which  is  likely  to  result  from  this  paralysis  is  flexion 
of  the  thigh  alone  or  with  abduction  of  the  leg,  a  condition  always 
associated  with  flexion  of  the  knee. 

Flexion  deformity  at  the  hip  produces  in  time  a  most  marked 


INFANTILE  PARALYSIS  273 

lordosis  in  the  back.  When  the  patient  stands  with  the  leg  dangling, 
the  weight  of  it  drags  upon  the  pelvis  and  rotates  it  on  a  transverse 
axis,  a  compensation  which  makes  it  possible  for  the  leg  to  hang  as 
nearly  as  possible  perpendicularly.  This  deformity  is  marked  and 
troublesome. 

At  the  knee,  contraction  in  the  flexed  position  (with  often  a  tend- 
ency to  subluxation  of  the  tibia  backward)  is  found,  and  in  the  more 


FIG.  242. — Hyperextension   of   the   Left   Knee   due  to   Paralysis   of   the   Limb.      Varus  deformity 

of  the  right  foot. 

severe  cases  decided  knock-knee.  In  severe  cases  of  this  type  in 
which  the  deformity  has  been  rectified  by  mechanical  or  operative 
means,  the  tibia  may  lie  in  a  plane  decidedly  posterior  to  that  of  the 
femur.  The  same  may  be  said  of  the  knock-knee  which  results  from 
the  greater  prominence  of  the  internal  condyle  of  the  femur.  The 
flexion  may  have  been  overcome,  but  still  a  decided  degree  of  knock- 
knee  may  remain  in  the  corrected  leg.  At  other  times  when  laxity 
rather  than  contraction  predominates,  hyperextension  of  the  knee  is 
observed  and  sometimes  lateral  mobility  also  exists. 

This  hyperextension  results  in  cases  in  which  the  anterior  muscles 


274 


ORTHOPEDIC  SURGERY 


are  weak  and  fail  to  hold  the  knee  extended  when  walking  is  at- 
tempted. In  these  cases  the  patient  throws  the  weight  of  the  body 
upon  the  fully  extended  knee  and  the  strain  falls  upon  the  ligaments 
rather  than  on  the  muscles.  The  posterior  ligaments  yield  in  time  to 
this  repeated  weight  and  the  patient  obtains  for  a  time  a  better  bear- 
ing. The  same  deformity  is  favored  by  a  tendency  which  these  pa- 
tients have  to  lean  with  the 
hand  upon  the  knee  when  ris- 
ing from  a  chair. 

Talipes  calcaneo-valgus  and 
pure  flat- foot  are  favored  by 
lax  ligaments,  and  the  latter 
may  be  a  progressive  deform- 
ity, which  may  increase  until  a 
stage  is  reached  in  which  the 
inner  malleolus  almost  touches 
the  ground.  The  bearing  of 
body-weight  on  a  foot,  the  liga- 
ments and  muscles  of  which  are 
weak,  tends  to  produce  flat- 
foot. 

Pure  talipes  calcaneus 
seems  to  be  the  result  of  the 
paralysis  of  the  posterior  calf 
muscles  combined  with  the  ac- 
tion of  gravity  and  superincum- 
bent weight,  and  is  commonly 
associated  with  what  is  known 
as  pes  cavus. 

Deformities  of  the  anus  are 
not  common  as  the  result  of  in- 
fantile paralysis.  The  least  in- 
frequent of  these  results  from 
the  paralysis  of  the  deltoid.  In 
addition  to  the  inability  to  raise 
the  arm  from  the  side,  there 

are  present  a  flattening  of  the  shoulder  and  a  prominence  of  the 
acromion  process,  and  the  shoulder  presents  an  angular  rather  than 
a  rounded  outline.  The  ligaments  are  loosened,  and  the  arm  hangs 
loosely,  so  that  in  some  cases  a  wide  gap  may  be  observed  between  the 
acromion  and  the  humerus. 


FIG.  243.— Paralysis  of  Both  Legs,  severest  in 
right,  with  knock-knee  on  that  side.  This  pa- 
tient was  unable  to  walk  without  crutches. 


INFANTILE  PARALYSIS 


275 


The  commonest  paralysis  of  the  hand  is  one  affecting  the  adductor 
muscles  of  the  thumb,  as  a  result  of  which  the  thumb  is  drawn  back 
to  a  level  with  the  other  fingers  and  the  power  to  oppose  it  to  the 
other  fingers  in  grasping  is  thus  lost.  Paralysis  of  the  erector  spinse 
muscles  results  in  a  permanent  arching  of  the  spine  and  inability  to 
sit  erect.  Paralysis  of  the  abdominal  muscles  causes  lordosis. 


FIG.  244. — Paralysis    of    the    Left    Arm    Muscles, 
Deltoid  and  Serratus  Magnus. 


FIG.    245. — Moderate    Degree    of    Ta- 
lipes Valgus,  Right  Foot. 


Lateral  curvature  of  the  spine  results  from  infantile  paralysis  in 
one  of  three  ways: 

(i)  From  the  inequality  in  the  length  of  the  legs  due  to  paral- 
ysis of  one  leg,  causing  tilting  of  the  pelvis.  (2)  From  the  uni- 
lateral paralysis  of  the  muscles  directly  controlling  the  vertebral 
column,  which  might  be  either  a  paralysis  of  the  intrinsic  spinal  mus- 
cles or  of  the  erector  spinse  group  on  one  side.  (3)  From  faulty 


276 


ORTHOPEDIC  SURGERY 


spinal  attitudes  assumed  in  consequence  of  some  paralysis  elsewhere, 
as  in  paralysis  of  one  arm,  or  of  the  serratus  magnus. 

Dislocations  from  Infantile  Paralysis. — Dislocation,  complete  or 
partial,  belongs  to  the  more  uncommon  of  the  complications  of  in- 
fantile paralysis  and  characterizes  severe  cases. 

Dislocation  or  subluxation  of  the  hip  is  the  one  most  commonly  met 
and  it  takes  place  either  spontaneously  or  in  consequence  of  weight 


FIG.  246. — Dislocation  of  Hip,  the  Result  of 
Infantile  Paralysis.  In  this  position  the 
head  of  the  femur  (left)  is  in  place,  but  with 
abduction  it  slips  out  again. 


FIG.    247. — Same    Case    as    Shown    in 
Fig.  246.    with   Hip   Dislocated. 


being  borne  upon  a  limb  which  is  improperly  supported  by  its  liga- 
ments. A  shortening  of  one  or  two  inches  may  be  present,  as  the 
dislocation  is  generally  on  to  the  dorsum  of  the  ilium ;  but  sometimes 
it  takes  the  form  of  a  laxity  of  the  joint  in  all  directions,  so  that 
the  head  may  be  thrown  into  any  position  by  manipulation  of  the 
shaft.  Most  dislocations  of  the  hip  are  inconvenient  chiefly  because 


INFANTILE  PARALYSIS 


277 


of  the  shortening  and  insecurity  which  follow  the  displacement  of 
the  head  of  the  bone,  and  such  legs  are  sometimes  fairly  serviceable. 
Dislocation  may,  however,  occur  before  any  weight  is  borne  upon  the 
affected  limb,  by  the  spontaneous  action  of  the  muscles,  as  in  a  patient 
eighteen  months  old,  in  the  experience  of  one  of  the  writers. 

DIAGNOSIS. 

In  typical  cases  the  diagnosis  of  infantile  paralysis  is  not  difficult. 
But  in  other  than  typical  cases  the  recognition  of  the  disease  may  be 
difficult,  and  it  is  not  possible  with  our  present  knowledge  to  establish 
a  positive  diagnosis  in  the  initial  stage.  At  that  time  the  occurrence 


FIG.   248. — Talipes  Varus,   Right   Foot. 

of  localized  pain  may  be  a  misleading  symptom,  and  sensitiveness  of 
the  affected  limbs  may  suggest  rheumatism. 

The  diagnostic  points  upon  which  the  practitioner  must  rely  in 
the  stage  of  established  paralysis  are  the  history  of  the  attack,  a 
motor  paralysis,  rapid  muscular  wasting,  the  distribution  of  the  paral- 
ysis, and  the  loss  of  the  tendon  reflex.  Diagnosis  by  the  determina- 
tion of  the  electrical  reaction  of  the  muscles  requires  especial  training 
and  skill,  although  it  is  distinctive. 

Electrical  Condition  of  the  Muscles. — Faradic  irritability  of  the 
affected  muscles  and  nerves  begins  to  diminish  within  a  day  or  two 


278 


ORTHOPEDIC  SURGERY 


of  the  onset  of  the  paralysis,  and  in  muscles  severely  affected  the 
electric  irritability  disappears  entirely;  in  the  muscles  less  seriously 
involved  it  is  merely  diminished.  The  cathodal  closing  contraction 
should  be  normally  greater  than  the  anodal  closing  contraction.  When 


FIG.  249. — Flexion  Defoimi'y  of 
the  Hip,  Knee,  and  Ankle,  due 
to  Contractions. 


Fie.  250. — Old   Paralysis  of  Left  Leg  with 
Slight  Knock-knte  and  Talipes  Yarus. 


nerves  and  muscles  affected  by  anterior  poliomyelitis  are  examined, 
not  only  a  slow  wave-like  response  to  electricity  instead  of  a  sharp 
quick  jerk  is  found,  but  the  electrical  formula  is  reversed  and  the 
closure  of  the  positive  pole  gives  the  greater  contraction.  These  quali- 
tative and  quantitative  changes  in  reaction  to  the  galvanic  current 
constitute  what  is  known  as  the  "  reaction  of  degeneration,"  and  this 


INFANTILE  PARALYSIS  279 

affords  the  most  definite  ground  for  the  diagnosis  of  infantile 
paralysis. 

The  only  affection  which  may  not  be  distinguished  by  electrical 
examination  from  anterior  poliomyelitis  is  peripheral  paralysis  caused 
by  interruption  in  the  course  of  some  nerve. 

The  most  available  means  for  the  practitioner  to  adopt  in  deter- 
mining which  muscles  are  paralyzed  is  as  follows :  The  patient  is  told 
to  dorsally  flex  the  foot,  and  the  examining  finger  is  placed  upon  the 
tendons  at  the  front  of  the  ankle  to  feel  which,  if  any,  contract; 
plantar  flexion,  adduction,  and  abduction  are  each  tested  in  the  same 
way.  The  activity  or  inactivity  of  each  muscle  can  thus  be  deter- 
mined. The  knee  is  flexed  and  extended,  with  the  fingers  on  the  ham- 
strings and  extensor  tendons,  and  the  hip  is  flexed,  extended,  rotated, 
and  adducted,  lying  on  the  back,  and  abducted  lying  on  the  side.  Cer- 
tain muscles  will  be  found  to  contract  feebly  and  should  be  classed 
as  "  weakened  "  rather  than  "  paralyzed." 

PROGNOSIS. 

So  far  as  danger  to  life  is  concerned,  from  5  to  15  per  cent  of 
patients  die  in  the  acute  attack.  If  death  does  occur  it  is  generally 
at  the  end  of  a  few  days,  oftenest  from  respiratory  paralysis. 

It  is  not  likely  that  the  paralysis  will  increase  if  it  has  been 
stationary  for  twenty-four  hours.  In  cases  in  which  the  deformity 
is  only  of  moderate  extent,  it  is  not  probable  that  life  will  be  short- 
ened by  it. 

When  untreated,  a  case  of  infantile  paralysis  will  almost  invariably 
improve  for  one  or  two  months  at  a  rapid  rate,  then  more  slowly  for 
two  or  three  months  more,  and  then  after  a  stationary  period,  con- 
tractions, looseness  of  the  joints,  and  malpositions  are  likely  to  begin, 
which  may  increase  indefinitely.  Under  treatment  the  prognosis  is 
much  more  favorable  and  the  limit  of  possible  improvement  extended 
by  many  years. 

It  should  be  remembered  that  even  in  mild  cases  of  infantile 
paralysis  bone  shortening  may  follow.  Certain  severe  cases  escape 
with  but  little,  while  a  mild  case  may  show,  with  the  wasting  of  the 
leg,  a  shortening  of  one  or  two  inches  in  the  limb  of  the  affected  side, 
or  more  in  exceptional  cases. 

A  distinct  measure  of  success  in  the  orthopedic  treatment  of  infan- 
tile paralysis  in  the  stage  of  deformity  can  be  expected  in  a  large 
percentage  of  cases,  exclusive  of  the  hopeless  class  where  a  large 
portion  of  the  body  is  permanently  paralyzed.  By  thorough  surgical 


280 


ORTHOPEDIC  SURGERY 


care  what  would  be  a  condition  of  hopeless  affliction  can  be  converted 
into  a  slight  or  endurable  disability. 


TREATMENT. 


The  treatment  of  infantile  paralysis  varies  according  to  the  stage 
at  which  treatment  is  to  be  undertaken. 

The  Stage  of  Onset. — If  the  fact  that  paralysis  is  present,  is  estab- 
lished during  the  febrile  attack,  which  is  usually  the  first  symptom  of 


FIG.  251. — Clawed  Toes  and  Pes  Cavus  following  Infantile  Paralysis. 


the  disease,  vigorous  treatment  should  be  at  once  begun,  to  limit,  if 
possible,  the  destructive  process  in  the  cord.  Cathartics  should  be 
given  at  once,  the  patient  should  be  kept  quiet  and  hexamethylenamin 
administered,  although  the  present  evidence  is  that  it  acts  best  as  a 
preventive  measure  than  after  the  infection  has  occurred.  Its  value 
is  probably  based  on  the  fact  that  it  sets  free  formalin  in  the  cerebro- 
spinal  fluid.  The  general  condition  of  the  child  should  in  every  way 
be  kept  as  good  as  possible.  The  child  should  be  isolated  and  sputum, 
urine,  and  feces  disinfected,  although  there  is  at  present  no  evidence 
to  show  how  long  the  infectious  period  lasts. 

The  Stage  of  Paralysis. — But  few  cases  are  seen  by  the  surgeon 
until  the  stage  of  paralysis  is  present.  The  question  that  then  presents 
itself  is  that  the  treatment  of  the  paralysis  should  be  such  that  the 
ultimate  amount  of  muscular  power  may  be  as  great  as  possible.  It 
must  be  remembered  that  the  tendency  of  the  paralysis  is  at  first 
very  strong  toward  spontaneous  improvement.  It  is  manifest  that 
in  the  first  few  weeks  treatment  should  be  directed  toward  producing 


INFANTILE  PARALYSIS  281 

conditions  which  shall  be  as  favorable  as  possible  for  the  spontaneous 
improvement  to  attain  its  maximum. 

This  stage  can  be  considered  to  extend  from  the  period  of  the 
entire  disappearance  of  the  sensitiveness  and  the  contractions  of  the 
early  irritant  stages  until  the  time  that  all  potential  power  has  been 
regained,  or  until  the  deformities  require  no  further  attention.  Two 
special  demands  are  important  throughout  this  stage,  which  are: 

1.  The  prevention  of  deformity. 

2.  The  regaining  of  nerve  and  muscle  power. 

1.  Prevention   of  Deformity — Deformities   which   occur  in   the 
course  of  recovery  from  infantile  paralysis  are  those  of  the  limbs  and 
those  of  the  spine,  a  form  of  scoliosis.     It  is  especially  needful  that 
apparatus  be  employed  in  this  stage  for  a  twofold  object,  i.e.,  first, 
to  prevent  the  overstretching  of  the  paralyzed  muscles  during  the  early 
stages ;  and,  second,  to  prevent  the  permanency  of  the  deformities 
mentioned. 

The  need  of  the  early  detection  of  a  faulty  position  of  the  spine 
and  of  early  care  in  the  prevention  of  scoliosis  cannot  be  too  strongly 
stated.  On  account  of  the  general  muscular  weakness  and  of  the 
unequal  pull  of  the  trunk  muscles,  the  asymmetrical  methods  of  walk- 
ing and  standing  and  the  faulty  superimposed  weight,  or  the  one-sided 
use  of  the  arms  in  cases  of  paralysis  of  the  upper  extremity,  all  mo- 
tions on  the  part  of  the  patient  tend  to  exaggerate  the  development 
of  deformity  when  once  under  way.  For  this  reason  this  form  of 
scoliosis  presents  a  most  obstinate  type  for  .  eatment,  and  as  soon 
as  there  is  any  evidence  of  a  beginning  defonr  y  of  the  spine  every 
effort  should  be  directed  to  check  its  development. 

2.  The  Regaining  of  Nerve  and  Muscle  Power. — It  is  possible  to 
gain  a  return  of  muscle  power  after  a  long  period  following  the  onset 
of  disease,  even  when  during  the  interval  there  has  been  no  evidence 
of  actual  local  return  of  power.     It  is  essential,  therefore,  that  treat- 
ment directed  to  this  end  be  carried  out,  not  only  in  a  most  thorough 
manner,  but  also  over  an  extended  period.     The  indications  during 
the  early  convalescent  stage  are  two,  viz. : 

(a)  The  stimulation  of  the  motor  tracts  to  prevent  all  possible 
degeneration  until  all  possible  repair  has  taken  place;  and 

(b)  Stimulation  and  protection  of  muscles  to  prevent  atrophy  and 
to  keep  the  muscle  in  condition,  that  it  may  respond  quickly  when 
nerve  impulses  are  restored. 

For  stimulation  of  nerves  and  muscles  the  means  to  be  employed 
are: 


282  ORTHOPEDIC  SURGERY 

1.  Muscle  training. 

2.  Physical    therapy    (including   mechanotherapy,    hydrotherapy, 
and  massage). 

3.  Electricity. 

4.  Baking  and  different  forms  of  high  heat. 

i.  Muscle  Training. — Probably  no  other  means  at  our  disposal  has 
a  more  important  place  or  more  extended  usefulness,  both  in  the 
variety  of  its  application  and  in  the  length  of  time  that  it  may  be 
used,  than  the  different  methods  which  may  be  grouped  under  this 
head.  It  is  applicable  as  soon  as  any  sign  of  returning  power  is 
found,  and  is  best  applied  through  the  "  assistive  form  "  of  exercise, 
which  has  the  advantage  of  allowing  actual  work  to  the  muscle  long 
before  power  is  sufficient  to  give  any  practical  result  in  movement. 
This  method  is  applied  in  detail  as  follows : 

The  part  to  which  the  muscle  belongs  is  put  through  passive  move- 
ment, with  slow  rhythm,  in  the  direction  that  is  desired.  The  patient 
is  then  directed  to  make  effort  to  move  the  part  in  the  same  direction 
to  whatever  extent  is  possible,  the  assistant  supplying  the  power 
needed  to  complete  the  actual  motion.  In  this  way  the  paralyzed 
muscle  is  allowed  to  contract  in  the  same  manner  as  if  it  were  doing 
the  whole  of  the  work,  and  has  the  benefit  of  the  contraction  and  of 
the  movement  during  the  whole  arc  of  motion.  As  the  muscle  becomes 
stronger,  the  assistive  force  supplied  becomes  less,  so  that  the  muscle 
is  allowed  to  take  up  more  of  the  work  during  the  whole  of  the 
exercise,  and  receives  the  maximum  amount  of  exercise  possible  to 
a  muscle  in  its  condition.  In  all  the  other  forms  of  exercise  one  must 
be  contented  with  the  mere  effort  of  the  muscle  to  make  contraction, 
without  allowing  contraction  through  a  distinct  arc  of  motion.1 

Poliomyelitis  nay  weaken  certain  muscles  without  paralyzing 
them  ;  it  is  desirable  to  lessen  the  disability  by  developing  their  strength 
again,  and,  as  far  as  possible,  to  secure  a  return  of  normal  motions  of 
the  limb.  This  can  usually  be  accomplished  by  systematic  exercises 
carried  out  regularly  once  or  twice  a  day.  Again,  certain  muscles  may 
be  weakened,  not  by  the  disease  itself,  but  by  disuse  entailed  by  it, 
although  not  in  themselves  involved  in  the  paralytic  attack.  For  these 
also  it  is  desirable  to  use  a  simple  means  of  exercise. 

The  aid  of  an  expert  is  undoubtedly  advisable,  but  the  constant 
daily  faithful  work  of  home  attendants  is  more  beneficial  than  occa- 
sional treatment  at  infrequent  intervals.  It  may  be  mentioned  that 
much  more  exercise  is  to  be  obtained  with  the  patient  immersed  in 
a  bath,  as  the  weight  of  the  limbs  is  supported  by  the  water. 
1  Wright:  Boston  Medical  and  Surgical  Journal,  1912,  Xo.  17,  567. 


INFANTILE  PARALYSIS 


283 


2.  Physical  Therapy  (including  Mechanothcrapy,  Massage,  etc.}. 
— Massage,  however,  should  be  given  a  high  place  in  all  stages  of 
this  affection  after  the  disappearance  of  the  tenderness.  In  conjunc- 
tion with  massage,  however,  it  is  wise  to  reiterate  the  caution  that 
it  is  necessary  not  to  rely  upon  massage  alone,  but  that  this  means 
should  be  regarded  as  an  adjunct  only  to  the  other  forms  of  muscle 
and  nerve  stimulation.  Too  frequently  it  is  the  case  that  massage 


FIG.  252. — Paralyzed  Child  Strapped  in  a  Walking  Frame  Wearing    Splints   to    Prevent 
Forward    Dropping   of    the  Knee.     (Boston  Med.  and  Surg.  Journal.) 

alone  is  used  to  the  neglect  of  many  of  the  other  means  fully  as 
important. 

3.  Electricity. — The  different  forms  which  may  be  used  for  this 
are  the  galvanic,  faradic,  static,  and  high-frequency  currents.  In  the 
early  stages  galvanism  should  be  used  on  the  nerve  trunks  and  faradism 
on  the  muscles,  so  long  as  their  irritability  for  contraction  is  main- 
tained. When  the  irritability  of  contraction  to  the  faradic  current  is 


284 


ORTHOPEDIC  SURGERY 


lost,  galvanism  should  then  be  used,  as  having  more  influence  on 
nutrition.  With  the  returning  muscle  irritability,  faradism  should  be 
used.  This  serves  as  a  distinct  exercise  to  the  muscle  during  its  early 


FIG.  253. — Child   Walking  with   Crutches  and   Splints.     (Boston  Med.  and  Surg.  Journal.) 

stage  of  weak  contraction.  High-frequency  and  static  electricity  can 
both  be  used  for  their  influence  on  nutrition  rather  than  for  their 
direct  action  on  muscle  contraction.  It  may  be  stated  in  this  con- 
nection that  the  main  dependence  for  actual  results  in  the  use  of  elec- 
tricity must  be  placed  upon  the  galvanic  and  faradic  currents. 


INFANTILE  PARALYSIS 


28; 


4.  Baking  and  the  Other  Means  of  Applying  High  Degrees  of 
Heat. — Paralyzed  limbs  in  these  cases  are  almost  always  cold  and  the 
circulation  distinctly  defective.  It  is  found  after  the  use  of  baking 


FIG.  254. — Side  View  of  "  Caliper  "  Splint,  with  Knee  Strap  and  Checks  in  the  Heel 
to  Prevent  the  Dropping  of  the  Heel  or  Front  of  the  Foot  as  maybe  needed.  (Boston 
Med.  and  Surg.  Journal.) 

by  electric  light  and  different  methods  of  applying  high  degrees  of 
heat  that  the  extremities  remain  warm  for  a  longer  time  and  that  the 
circulation  is  more  active ;  and  that  the  patient  is  able  to  use  the  very 


286 


ORTHOPEDIC  SURGERY 


weak  muscles  better  during  the  time  that  the  limbs  remain  warm.  It 
is  frequently  found  that  after  continued  use  of  high  degrees  of  heat 
this  improvement  of  circulation  and  the  local  heat  of  the  limb  become 
more  and  more  permanent,  frequently  lasting  for  the  larger  part  of 
the  day  or  longer. 

MECHANICAL  TREATMENT. 

The  objects  of  mechanical  treatment  for  infantile  paralysis  are: 
I.  To  correct  the  deformities  of  the  limb. 


FIG.  255. — Detail  of  Wire  Splint,  Showing  Adjustment  to  the  Shoe,  with  Check  to  Prevent 
Toe-drop.    (Boston  Med.  and  Surg.  Journal.) 

2.  To  prevent  the  development  of  new  deformities. 

3.  To  aid  locomotion  by  furnishing,  through  the  mechanical  stops 
and  checks,  a  substitute  for  the  action  of  muscles  weakened  or  para- 
lyzed by  the  disease. 

The  number  of  types  of  appliances  which  can  be  devised  is  great. 
Those  which  are  simple,  light,  easily  designed,  and  easily  applied  are 
to  be  preferred.  Expensive,  heavy,  and  complicated  forms  of  ap- 
paratus are  undesirable. 


INFANTILE  PARALYSIS 


287 


Those  which  have  been  for  many  years  used  at  the  Boston  Chil- 
dren's Hospital  will  be  referred  to  here  because,  in  design  and  con- 
struction, they  are  suited  to  the  practice  of  any  general  practitioner 
who  is  ready  to  give  personal  attention  to  making,  fitting,  and  adjust- 
ing an  appliance  to  prevent  the  development  of  deformity  in  his 
patient. 

Early  Stage  of  Paralysis. — Appliances  for  this  stage  should  inter- 
fere with  the  circulation  as  little  as  possible,  since  it  is  desirable  to 
develop  the  impaired  nutrition  and  circulation,  not  to  impede  it.  For 

this  reason  plaster  bandages  and 
splints  tightly  secured  by  a  muslin 
bandage  are  less  used  than  for- 
merly. 

Toe-drop  can  easily  be  pre- 
vented while  the  child  is  in  bed 
by  fixing  the  limb  on  a  simple  pos- 
terior wire  splint  such  as  one  uses 
for  fractures.  If  this  splint  be 
prolonged  to  reach  the  upper  part 
of  the  thigh,  and  is  made  stiff 
enough,  contraction  of  the  knee 
can  also  be  prevented. 

Splints  for  Walking. — These 
splints  are  designed  for  two 
classes  of  cases — those  in  which  a 
flaccid  paralysis  is  present  in  some 
of  the  muscles,  and  those  where, 
in  addition  to  the  paralysis,  a  con- 
traction and  shortening  has  taken 
place  in  muscles  which  are  not 
paralyzed  but  have  lost  their  an- 
tagonists. In  the  first  class  no  stiffness  or  contraction  is  present,  and 
splints  may  be  needed  to  prevent  (i)  toe-drop;  (2)  dropping  of  the 
tarsus  to  the  inner  side;  (3)  dropping  of  the  tarsus  to  the  outer  side; 
(4)  walking  on  the  heel;  and  (5)  to  hold  the  knee  straight  in  paralysis 
of  the  muscles  of  the  front  of  the  thigh. 

Where  no  stiffness  from  contraction  is  present,  a  simple  apparatus 
can  be  furnished  to  prevent  toe-drop.  It  is  called  a  short  caliper  splint. 
It  consists  of  two  parts,  the  splint  and  the  socket  attached  to  the 
boot. 

The  socket  is  made  of  a  thin  iron  plate,  made  to  fit  under  the 


FIG.  256. — Apparatus  to  Prevent  Toe-drop 
Slipping  in  a  Socket  at  the  Heel.  An 
ankle  strap  secures  the  leg. 


288 


ORTHOPEDIC  SURGERY 


heel  and  the  shank  of  the  child's  boot,  as  far  forward  as  the  meta- 
tarso-phalangeal  joint.  The  heel  of  the  boot  is  first  removed,  and 
a  deep  groove  or  socket  is  fashioned  in  the  plate  by  forging,  so  that 
when  it  is  applied  to  the  boot  it  will  receive  at  the  heel  the  end  of 
the  upright,  as  if  in  a  tube.  A  small  spur  piece,  which  is  left  projecting 


FIG.  257.— Apparatus  Similar  to  Fig.  256-  with  Ankle  Strap  to  Check  Paralytic  VaU 
gus.  If  the  upright  is  applied  to  the  inside  with  the  ankle  strap  applied  to  the 
outside  a  varus  deformity  is  checked.  (Boston  Mod.  and  Surg.  Journal. > 

outside  the  boot,  is  bent  up  after  it  is  applied,  so  as  to  act  as  a  stop, 
as  shown  in  the  illustration,  and  the  boot  heel  is  reapplied. 

At  the  top  the  wires  are  slightly  flattened  and  attached  to  a  thin 
metal  calf-band  fitted  to  the  calf  of  the  leg;  at  the  bottom  they  are 
sharply  bent  inward  at  a  right  angle  so  as  to  fit  in  the  socket.  The 
uprights  may  follow  the  shape  of  the  leg,  or  be  left  straight.  This 
brace  is  held  in  place  by  a  strap  at  the  top  and  one  around  the  ankle. 

Should  the  patient,  instead  of  having  toe-drop,  have  paralysis  of 
the  calf  muscles,  he  will  walk  on  his  heel.  In  order  to  apply  the 
sole  of  the  boot  to  the  ground,  the  same  splint  may  be  used  to  advan- 
tage if  the  socket  be  made  so  that  the  stop  comes  in  front  of  the 
upright  instead  of  behind  it. 

Should  the  child  stand  with  the  foot  in  the  varus  or  club-foot 
position,  a  stout  leather  T  strap  should  be  added,  which  is  sewed  to 
the  upper  of  the  boot,  just  in  front  of  the  external  malleolus;  the 
horizontal  straps  buckle  into  each  other  and  include  the  inner  upright 
of  the  splint. 

Should,  on  the  other  hand,  a  pronated  or  valgus  position  appear 
in  weight-bearing,  the  T  strap  should  be  on  the  opposite  side  of  the 


INFANTILE  PARALYSIS 


280 


boot  below  the  inner  malleolus,  and  strapped  around  the  outer  upright 
so  as  to  maintain  the  arch  of  the  foot  by  preventing  the  ankle  from 
sagging  inward. 

Again,  if,  owing  to  paralysis  of  the  muscles  of  the  fruit  of  the 


FIG.  258. — Caliper  Apparatus  for  Anterior 
Poliomyelitis. 


FIG.  259. — Supporting  Splint  for  Use  in 
Infantile  Paralysis.  It  prevents  flexion 
of  the  knee  in  standing,  but  is  provided 
with  a  lock-joint  at  the  knee. 


thigh,  the  quadriceps  extensor  cruris,  the  child  cannot  hold  the  knee 
stiff  in  standing,  then  the  caliper  splint  should  be  made  to  reach  the 
unper  part  of  the  thigh  and  the  knee  be  kept  straight  by  a  leather 
knee  cap. 


290 


ORTHOPEDIC  SURGERY 


Firmer  and  more  efficient  apparatus  is  the  following : 

In  toe-drop  the  same  end  can  be  accomplished  by  the  application 

of  a  walking  appliance,  described  under  club-foot  as  an  equino-varus 

shoe,  which  should  be  provided  with  a  right-angle  stop  at  the  ankle 

which  will  not  allow  the  ankle  to  be  extended  to  more  than  a  right 


O 


:l 


FIG.  260. — Self-locking  Spring  Catch. 


FIG.  261. — Drop  Catch. 


angle.  When  in  bearing  weight  upon  the  leg  the  ankle  assumes  a 
varus  position,  a  varus  shoe  will  correct  the  tendency  to  deformity. 

If  the  foot  rolls  out  and  is  everted  into  a  valgus  condition  when 
the  body  weight  is  borne  upon  the  leg,  an  outside  shoe  is  to  be  ap- 
plied, in  construction  like  the  varus  shoe,  but  which  should  have  a 
broad  leather  strap  which  should  pass  around  the  inner  malleolus  and 
support  it.  This  apparatus  is  a  difficult  one  to  render  quite  comforta- 
ble to  the  patient,  as  much  weight  must  necessarily  come  upon  the 
strap  which  supports  the  inner  malleolus.  As  flat-foot  is  almost  always 
present  in  these  cases,  it  is  well  to  arch  the  steel  sole  plate  of  this 
apparatus  so  that  it  serves  as  a  valgus  plate  as  well  as  a  supporting 
appliance. 

If  calcaneus  is  present  the  apparatus  spoken  of  for  equinus  is  used, 
with  the  stop  catch  reversed  to  prevent  dorsal  instead  of  plantar 
flexion. 

PCS  cants  may  be  treated  by  inserting  a  steel  sole  in  the  sole  of 


INFANTILE  PARALYSIS 


the  boot  and  passing  a  strap  from  the  sole  over  the  dorsum  of  the 
foot.  This  treatment  is  made  much  more  efficient  if  combined  with 
preliminary  division  of  the  plantar  fascia.  Mechanical  treatment  alone 
is  likely  to  be  unsatisfactory. 

It  is  manifest  that  the  simpler  and  lighter  these  appliances  are 
and  the  less  unsightly,  the  more  serviceable  they  will  prove.     For 


FIG.  262.  FIG.  263. 

FIGS.  262.  and  263. — Supporting  Apparatus  in  Paralysis  of  Anterior  Thigh  Muscles. 

this  reason  they  should  be  carefully  fitted  and  the  uprights  made  to 
follow  the  outline  of  the  leg.  In  very  slight  cases,  in  which  there  is 
only  a  slight  eversion  of  the  foot  with  a  small  degree  of  valgus,  a 
common  valgus  plate,  such  as  would  be  applied  for  flat-foot,  will  often 
answer  every  purpose  in  correcting  the  deformity,  and  it  should  be 
applied  as  in  simple  flat-foot. 

If  the  knee  tends  to  drop  backward  and  become  hyperextended,  it 
can  be  remedied  by  an  appliance  with  a  strap  passing  behind  the  knee, 
with  an  upper  band  encircling  the  thigh.  In  practice  this  apparatus 
can  often  consist  of  a  single  outside  upright  hinged  at  the  knee.  It 
passes  to  the  inside  of  the  leg  just  below  the  knee  to  become  attached 
to  a  varus  shoe.  This  answers  as  well  as  a  double  upright  in  many 
cases. 

Other  cases,  in  which  the  paralysis  is  more  severe,  require  the 
two  uprights,  as  they  furnish  a  more  definite  support.  The  foot  is 


292  ORTHOPEDIC  SURGERY 

easily  retained  to  the  steel  sole  plate  by  straps  or  a  piece  of  leather 
lacing  over  the  instep.  The  fenestrated  knee  cap  is  the  most  com- 
fortable method  of  holding  the  knee  extended. 

Although  in  walking  it  is  generally  necessary  to  have  the  knee 
kept  extended  by  the  splint,  yet  in  sitting  down  it  is  a  great  comfort 
to  the  patient  to  be  able  to  flex  the  knee,  and  for  this  rea^cn 
nearly  all  splints  should  be  hinged  at  the  knee,  in  the  case  of  elder 
children. 

TREATMENT   OF   CONTRACTIONS. 

Eqninus  Deformity. — In  slight  degrees,  contraction  of  the  short 
tendo  Achillis  can  be  overcome  by  stretching  the  muscles  with  a  special 
splint  in  walking,  if  the  heel  can  be  held  down  firmly  against  a  foot 
plate  which  extends  well  forward,  while  toe-drop  is  prevented  by  a  stop 
in  the  ankle-joint  of  the  upright.  At  times  it  is  hard  to  accomplish 
this  because  the  heel  refuses  to  stay  down  on  the  sole-plate,  but  it  may 
be  held  there  either  by  a  strong  ankle  strap  or  by  a  strip  of  adhesive 
plaster  attached  to  the  skin  of  the  calf  of  the  leg  above  and  to  the 
lower  surface  of  the  sole-plate  below.  Such  an  apparatus  can  be  worn 
inside  of  the  boot,  the  correcting  force  being  the  body  weight. 

I 'ants  TV.'///;  Slight  Contraction. — In  paralytic  varus  deformity  a 
thick  leather  wedge  is  pegged  to  the  lower  surface  of  the  sole  of  the 
boot  under  the  cuboid,  so  that  the  foot  in  walking  strikes  first  on  the 
heel,  then  on  the  wedge  which  projects  more  than  the  heel,  and  forces 
the  foot  to  turn  outward  to  prevent  loss  of  balance,  so  that  the  foot 
at  the  end  of  a  step,  before  leaving  the  ground,  receives  the  body 
weight  wholly  on  the  abducted  front  portion. 

J'algus  with  Slight  Contraction. — In  paralytic  valgus  deformity, 
when  the  contraction  of  the  peronei  muscles  is  slight,  the  position  of 
the  walking  foot  as  it  bears  on  the  ground  can  be  improved  by  sup- 
porting the  sagging  arch,  both  by  an  upright  and  T  strap,  and  by 
pegging  a  thick  wedge  of  leather  on  the  lower  surface  of  the  sole 
of  the  boot,  extending  forward  along  the  inner  side  from  the  heel  to 
the  scaphoid,  or  under  the  first  metatarsal,  as  the  case  may  require. 

Calcancns. — In  cases  with  slight  contraction  the  position  of  the 
walking  foot,  as  it  strikes  the  ground,  can  be  improved  by  prolonging 
the  heel  backwards  or  by  raising  the  heel  of  the  shoe. 

The  above-mentioned  appliances  are  only  for  slight  contractions; 
when  firm  contractions  have  developed,  they  are  to  be  stretched  or 
divided  by  an  operation,  under  full  anaesthesia,  either  by  manual  force, 
tenotomy,  or  incision,  as  may  be  needed;  but  for  a  few  mild  cases 


INFANTILE  PARALYSIS  293 

the  gradual  corrections  are  sufficient  which  one  obtains  by  plaster 
bandages  or  mechanical  appliances. 

Plaster  Bandages. — Gradual  correction  by  the  frequently  repeated 
application  of  plaster  bandages  is  obtained  by  holding  the  limb  in 
as  corrected  a  position  as  possible  while  the  plaster  sets,  without  the 
aid  of  an  anaesthetic.  It  is  effective  in  recent  contractions  in  young 


FIG.  264. — Heel    Extension   to  be  Used  to   Check  Calcaneus   Deformity. 
(Boston  Med.  and  Surg.  Journal.) 

children.  The  method  has  to  its  disadvantage  that  both  muscular 
atrophy  and  weakening  of  undestroyed  muscles  are  favored  by  the 
prolonged  use  of  stiff  bandages ;  therefore  this  method  should  not 
be  continued  during  a  long  period. 

The  contractions  which  the  surgeon  has  most  frequently  to  over- 
come are  those  of  the  tendo  Achillis,  the  hamstrings,  the  tensor  vaginae 
femoris  and  fascia  adjacent,  the  psoas  and  iliacus  muscles ;  also  con- 
tractions of  the  tendons  and  fascia  of  the  foot. 

For  the  correction  of  contracted  ankle',  unless  the  equinus  position 
yields  readily  to  mechanical  means,  tenotomy  of  the  tendo  Achillis,  is 
decidedly  preferable. 

For  a  contracted  or  flexed  knee,  mechanical  measures  are  better 
adapted.  If  the  type  be  mild  it  can  be  overcome  by  the  application 
of  a  splint  resembling  Thomas'  knee-splint,  to  which  the  limb  can 
be  bandaged.  The  corrective  pressure  is  obtained  largely  from  the 
bandage  over  the  thigh  and  knee,  which  should  be  applied  at  least 
twice  a  day.  This  apparatus  can  also  be  used  to  walk  with.  If  any 
form  of  acquired  talipes  is  combined  with  the  contracted  knee,  it  may 
be  corrected  simultaneously  in  the  manner  already  described. 

For  contractions  of  the  hip- joint  not  severe  enough  to  demand' 
operation,  two  common  methods  of  correction  are  in  use. 

i.  By  encasing  in  a  plaster  bandage  the  limb,  with  the  knee 
straight,  may  be  utilized  to  stretch  very  gradually  the  contracted  mus- 
cles and  fasciae  of  the  hip ;  this  may  be  done  either  while  the  child  is 
walking  about,  or,  preferably,  while  he  is  in  bed,  on  a  bed  frame. 


294 


ORTHOPEDIC  SURGERY 


Sometimes  a  separate  plaster  jacket  is  required  for  these  recumbent 
cases,  to  prevent  lordosis  of  the  lumbar  spine. 

2.  A  direct  pull  or  traction  may  be  used,  such  as  one  would  use  to 
correct  flexion  in  hip  disease.  The  patient  is  then  kept  on  a  bed  frame 
with  the  pelvis  fixed  (by  extreme  flexion  of  the  unaffected  thigh,  if 


FIG.  265. — Jacket   Attached   to   Caliper    Splints   Applied   to   a   Case   of   Paralysis  of   the   Trunk 

and  of  Both  Legs. 


necessary)  with  the  paralyzed  leg  elevated,  and  traction  is  applied 
in  such  a  position  that  the  line  of  pull  coincides  with  the  new  direc- 
tion of  the  femur ;  traction  is  first  made  in  this  direction,  and  from 
this  position  the  limb  is  straightened  very  gradually  day  by  day. 

Flexion  Contraction  at  the  hip  when  of  even  moderate  grade  is 
a  serious  impediment  to  walking  and  is  successfully  relieved  by  an 
operation   recently   devised   by    Soutter,1    which   should    replace   the 
1  Soutter:  Boston  Med.  and  Surg.  Journal,  1914,  clxx.,  38. 


INFANTILE  PARALYSIS  295 

myotomy  in  former  use  which  was  unsatisfactory.  A  vertical  in- 
cision some  two  or  three  inches  in  length  is  made  about  an  inch 
behind  the  anterior  superior  iliac  spine,  which  should  come  opposite 
the  middle  of  the  incision.  The  fascia  lata  is  exposed  as  far  back 
as  the  trochanter  and  divided  obliquely  in  a  line  extending  from  the 
anterior  superior  spine  to  the  tip  of  the  trochanter.  An  osteotome 
is  now  inserted  down  to  the  anterior  superior  spine  of  the  ilium  and 
all  the  muscular  attachments  are  removed  subperiosteally  on  the  inner 
and  outer  border  and  up  on  the  crest  of  the  ilium  (no  muscle  is  cut). 
The  leg  is  now  hyperextended  and  all  the  tissues  about  the  anterior 
superior  are  pushed  down  with  a  piece  of  gauze.  The  divided  fascia 
is  not  united. 

Although  all  operative  measures  are  theoretically  undesirable  in 
cases  of  extreme  paralysis  in  children  because  the  operation  and  post- 
operative fixation  tend  to  muscular  deterioration,  still  it  must  be  re- 
membered always  that  a  fixed  deformity  is  an  insuperable  obstacle 
to  successful  mechanical  treatment  and  that  it  must  be  removed  by 
the  least  objectionable  means  at  our  disposal. 

Lateral  curvatures  from  poliomyelitis  sometimes  require  treatment 
by  recumbency  to  obliterate  or  diminish  the  curves,  but  in  most  in- 
stances plaster  corrective  jackets  are  required  for  the  severe  types  of 
curvature,  and  the  subsequent  use  of  stiff  leather  or  celluloid  corsets 
is  often  necessary  for  a  long  time  to  keep  the  curvature  from  increas- 
ing. (See  chapter  on  Scoliosis. )  These  can  be  connected  with  the 
leg  appliances,  if  necessary,  and  will  afford  assistance  in  standing. 
Cases  of  this  sort  may  be  so  severe  as  to  require  the  use  of  crutches 
for  locomotion. 

When  the  abdominal  muscles  are  affected,  abdominal  bands  or 
corsets  will  serve  to  correct  the  malposition  of  the  trunk  to  a  certain 
extent. 

The  mechanical  treatment  of  paralysis  of  the  arm  is  less  satisfac- 
tory than  that  of  the  lower  extremity.  Apparatus  is  of  little  value, 
and  in  these  cases  operative  measures  offer  the  best  chance  of  relief. 
When  mechanical  measures  are  undertaken  they  should  consist  of 
protection  of  the  deltoid  from  all  dragging  of  the  weight  of  the  arm, 
by  supporting  the  latter  on  a  wire  support  if  necessary,  which  holds 
it  at  the.  level  of  the  shoulder. 

OPERATIVE   TREATMENT. 

The  object  of  operative  interference  in  paralytic  affections  is  two- 
fold: 


296  ORTHOPEDIC  SURGERY 

i st.  To  correct  existing  deformity. 

2cl.  To  render  the  paralyzed  limb  more  efficient. 

The  first  division  of  the  subject  has  been  already  discussed. 

The  second  will  be  considered  under  the  subdivisions  of  (a)  mus- 
cle and  tendon  transference,  (b)  arthrodesis,  (c)  silk  ligaments,  (d) 
bone  operations. 

Muscle  and  Tendon  Transference. 

Where  certain  groups  of  muscles  are  paralyzed  and  the  opponents 
remain  strong,  a  transference  of  one  or  more  of  the  strong  muscles 
to  perform  the  function  of  the  weak  muscles  has  been  proved  to  be 
of  benefit.  Tendon  grafting,  that  is,  the  insertion  of  the  tendon  of 
a  strong  muscle  int.,  the  tendon  of  a  weak  muscle,  although  tem- 
porarily a  help,  has  net,  as  a  rule,  been  found  to  be  as  permanently 
beneficial  as  the  transference  of  muscle  or  tendon  with  the  periosteal 
insertion  of  the  transferred  tendon  to  a  point  of  bone  where  a  strong 
attachment  can  be  secured  to  the  periosteum  or  the  bone  itself.  This 
gives  a  proper  point  for  the  contraction  of  the  transferred  muscle 
to  perform  the  function  lost  by  the  paralytic  attack.  Where  the 
transferred  muscle  or  tendon  is  not  sufficiently  long  to  furnish  a 
periosteal  insertion,  the  tendon  can  be  elongated  by  means  of  silk 
strands  properly  prepared.  This  measure  is  especially  suitable  in 
paralytic  affections  of  the  foot,  of  the  knee,  and  of  the  shoulder- 
joint;  it  has  also  been  used  for  paralyzed  muscles  about  the  hip. 
Strictly  aseptic  precautu  ns  are  necessary.  Heavy  silk,  Xo.  12  to  18, 
is  boiled  for  half  an  hour  in  i-iooo  solution  of  corrosive  sublimate 
or  oxycyanide  of  mercury,  and  then  boiled  with  the  instruments  to 
be  used  in  the  operation.  This  method  of  preparation  has  replaced 
the  former  and  complicated  method  with  paraffin  and  is  apparently 
quite  as  free  from  risk.  These  silk  strands  are  quilted  into  the  tendon 
of  the  muscle  to  be  transferred.  The  tendon  is  then  divided,  and,  \vith 
the  silk  strands  attached,  is  passed  by  means  of  long  forceps  through 
the  subcutaneous  tissue  and  brought  out  through  an  incision  at  the 
point  needed  for  periosteal  insertion.  The  silk  strands  are  then  in- 
serted by  means  of  proper  needles  into  the  periosteum  or  bone  tissue, 
the  foot  being  placed  in  an  overcorrected  position.  In  some  instances 
it  may  be  well  to  supplement  tendon  transference  with  silk  ligaments. 

In  quadriceps  paralysis  of  the  knee-joint,  the  hamstrings  can  be 
transferred  forward  and  inserted  into  the  patella  and  into  the  liga- 
mentnm  patella?.  In  deltoid  paralysis,  strands  of  the  trapezius  have 


INFANTILE  PARALYSIS  297 

been  transferred  in  such  a  way.  In  paralysis  of  the  glutei  muscles, 
the  vastus  or  the  rectus  femoris  have  been  utilized  for  transference, 
and  also  strands  of  the  erector  spinae.  In  paralysis  of  the  tibial  mus- 
cles, the  peronei  have  been  transferred,  and  vice  versa.  In  paralysis 
of  the  extensor  communis  of  the  foot,  the  flexors  have  been  used,  or 
portions  of  the  tendo  Achillis. 

For  success  it  is  essential  that  the  muscular  balance  in  the  para- 
lyzed limb  be  restored,  and  for  this  it  is  necessary  that  the  transferred 
muscle  pass  to  its  new  insertion  in  the  line  in  which  the  muscular 
pull  is  desired.  It  is  essential  that  the  transferred  muscle  should  not 
be  relaxed  and  that  it  should  have  a  firm  and  an  effective  attachment. 

The  operation  is  done  after  the  limb  has  been  made  bloodless  by 
the  Esmarch  method,  and  the  deformity  of  varus,  valgus,  or  equinus 
must  be  forcibly  corrected  with  tenotomy  and  fasciotomy  if  neces- 
sary. The  correction  of  the  deformity,  if  severe,  should  be  preferably 
done  a  few  days  before  the  tendon  operation.  In  the  more  mild  cases 
the  correction  can  be  done  at  the  same  sitting  with  the  operation. 
A  long  incision  is  then  made  over  the  middle  of  the  ankle  or  the 
part  of  the  ankle  where  the  tendons  to  be  operated  on  are  situated, 
extending  to  the  dcrsum  of  the  foot.  The  muscle  to  be  transferred 
is  then  selected  and  the  tendon  isolated  and  cut  off  as  near  its  inser- 
tion as  possible.  The  end  is  then  secured  by  a  long,  stout,  silk  suture. 
The  muscular  portion  is  freed  above  sufficiently  to  permit  a  trans- 
ference of  the  direction  of  the  muscle  in  a  nearly  straight  rather  than 
a  curved  course.  The  desired  point  of  insertion  is  then  selected, 
which  should  be  as  far  forward  on  the  tarsus  as  is  practicable.  The 
tendon  itself,  or,  if  it  is  too  short  to  reach,  the  silk  attached  to  the 
freed  tendon  is  then  stitched  securely  to  the  periosteum  at  the  selected 
point,  the  tendon  pulled  tightly  into  its  new  position,  and  firmly  tied. 

Whether  the  tibialis  anticus  or  the  peroneus  longus,  e.g.,  is  selected 
in  a  given  operation,  depends  upon  the  location  of  the  paralysis  and 
the  muscular  pull  desired. 

The  operative  reduction  of  calcaneus  or  calcanco-valgns  is  not 
permanently  accomplished  by  simple  shortening  of  the  tendo  Achillis, 
because,  being  paralyzed,  the  tendon  will  again  stretch  and  the  de- 
formity recur. 

If  an  element  of  ralgiis  exists  with  the  calcaneus,  some  of  the 
tendons  of  the  common  extensor  should  be  cut  and  given  a  periostea! 
insertion  into  the  scaphoid  or  cuneiform.  But  in  general  it  is  prefer- 
able to  change  the  insertion  of  one  of  the  peronei  muscles  to  the 
inner  border  of  the  foot. 


298  ORTHOPEDIC  SURGERY 

In  the  correction  of  vanis  the  anterior  tibial  muscle  tendon  may 
be  transferred  to  the  outer  side  of  the  foot,  but  this  is  an  operation 
to  be  performed  with  caution,  as  overcorrection  may  result  as  the 
weight-bearing  position  of  the  unsupported  foot  tends  toward  valgus. 

In  pcs  cavus  the  plantar  fascia  is  to  be  tenotomized,  the  foot  forci- 
bly stretched,  with  an  ostectomy  of  the.  tarsus  in  extreme  cases.  Oste- 
otomy of  the  os  calcis  is  also  to  be  considered  in  pronounced  varus 
and  valgus  with  distortion  of  that  bone.  The  proceeding  is  similar 
to  that  in  congenital  club-foot. 

After-Treatment. — After  the  operation  the  limb  should  be  pro- 
tected by  sufficient  sheet  wadding  and  fixed  in  the  desired  over- 
corrected  position  in  a  plaster-of-Paris  bandage,  arranged  so  as  to 
allow  the  required  inspection  after  dressing.  After  six  weeks  the 
plaster  bandage  is  to  be  followed  by  a  retention  apparatus,  to  be  worn 
for  a  year,  such  as  has  already  been  described,  and  the  gradually  in- 
creasing use  of  the  limb  allowed,  along  with  massage  and  passive 
exercises  to  develop  the  transferred  muscles  to  their  new  work. 

Arthrodcsis. 

If  weight  is  thrown  upon  a  paralyzed  lower  extremity  the  knee 
bends  forward  and  the  patient  falls.  It  is  evident  that  if  the  knee- 
joint  is  stiffened  in  such  a  way  that  it  cannot  bend,  the  bones  will 
be  capable  of  sustaining  the  superimposed  weight.  This  can  be  made 
possible  at  the  hip,  ankle,  and  midtarsal  joints.  The  operation  of 
joint  stiffening  is  known  as  arthrodesis.  The  cartilaginous  surfaces 
of  the  twro  adjacent  bones  are  removed  in  the  expectation  that  the 
tared  bone  surfaces  will  unite,  forming  an  ankylosis,  and  a  stiff  joint 
result.  Practical  experience  has  sho\vn  that  this  method  should  not 
be  undertaken  in  children  under  ten,  as  in  young  children  the  ends 
of  the  bones  are  largely  cartilaginous,  and  the  amount  which  it  is 
necessary  to  remove  to  obtain  an  ankylosis  is  considerable;  and  in 
addition  to  this,  in  children,  when  a  growth  of  the  limb  takes  place, 
the  limb  may  grow  in  a  direction  of  distortion.  The  operation  of 
arthrodesis  can  also  be  applied  to  the  shoulder- joint.  In  the  shoulder- 
joint  the  arm  should  be  after  operation,  during  the  period  of  healing, 
placed  in  a  position  somewhat  abducted  from  the  body. 

Arthrodesis  of  the  hip-joint  is  less  frequently  needed  and  is  often 
unsuccessful,  but  has  been  found  beneficial  in  instances  where  the 
hip  is  unstable  and  subluxated.  Arthrodesis  at  the  knee-joint  leaves 
the  patient  with  an  awkward  limb,  which  for  practical  purposes  is 


INFANTILE  PARALYSIS  299 

not  as  serviceable  as  one  supplied  with  a  suitable  prosthetic  appliance. 
In  certain  instances,  however,  where  it  is  difficult  to  furnish  a  proper 
apparatus,  patients  often  prefer  the  inconvenience  of  a  stiff  knee  to 
the  constant  use  of  an  appliance.  Arthrodesis  of  the  knee  should 
not  be  done  until  the  growth  has  stopped. 

In  deformities  of  the  foot,  where  no  muscular  strength  remains 
and  the  patients  are  not  young,  an  arthrodesis  between  the  astragalus 
and  tibia,  the  os  calcis  and  astragalus,  and  the  midtarsal  articulations 
(the  astragalo-scaphoid  and  calcaneocuboid)  is  often  of  benefit;  but 
the  use  of  silk  ligaments  is  to  be  preferred. 

Silk  Ligaments. 

Limitation  of  the  motion  of  a  joint  by  means  of  the  insertion  of 
silk  strands,  properly  sterilized,  quilted  in  the  periosteum  of  the  bones 
adjacent  to  the  affected  joint  or  inserted  through  drill  holes  in  the 
bone,  replaces  arthrodesis  in  preventing  toe-drop  and  checking  the 
slighter  forms  of  valgus  and  varus  in  children  and  adolescents.  The 
method  is  one  which  requires  technical  skill  and  experience. 

It  has  been  found  that  these  silk  ligaments,  properly  inserted,  re- 
main in  the  tissues  and  become  in  time  surrounded  by  fibrous  tissue, 
which  serve  the  purpose  of  checks,  capable  of  permanently  preventing 
the  development  of  severe  deformity. 

If  it  is  desired  to  prevent  toe-drop  in  a  paralyzed  ankle,  the 
technique  is  as  follows :  The  periosteum  of  the  tibia  is  slit  longi- 
tudinally 2  or  3  inches  above  the  ankle-joint  and  silk  in  size  from  14 
to  20  is  quilted  into  the  everted  edges  of  the  periosteum,  or  passed 
through  holes  drilled  in  the  bone.  Two  or  more  silk  strands  are  then 
carried  down  under  the  annular  ligament  of  the  ankle  by  a  flat  di- 
rector with  an  eye,  and  brought  out  through  an  incision  over  the 
desired  place  of  insertion  on  the  tarsus.  This  may  be  at  the  outer  or 
inner  side  or  in  the  middle  line,  in  the  first  two  instances  to  correct 
a  tendency  toward  valgus  or  varus  deformity.  At  the  site  of  the 
insertion  a  pointed  heavy  curved  needle  is  carried  through  the  bone 
and  by  a  loop  of  silkworm  gut  carried  through  the  eye  of  this  needle  ; 
the  silk  is  carried  through  the  bone  and  knotted  firmly,  with  the 
strands  tight  when  the  foot  is  in  the  desired  position.  The  fascia, 
subcutaneous  tissue,  and  skin  are  then  united  over  the  silk,  a  plaster- 
of-Paris  bandage  is  applied  over  the  dressing  and  worn  ior  8  to  JO 
weeks,  after  which  a  fixation  shoe  is  desirable  to  prevent  strain  on 
the  new  ligament  for  at  least  one  year. 

The  advantage  over  arthrodesis  is  that  dorsal  flexion  of  the  foot 


300  ORTHOPEDIC  SURGERY 

is  possible  while  plantar  flexion  is  checked.     The  application  of  the 
technique  to  other  localities  does  not  differ  in  essentials. 

Bone  Operations. 

iriiittnan's  Operation. — Tn  cases  of  calcaneus  deformity,  that  is, 
the  paralytic  deformity  where  the  weight  is  borne  on  the  end  of  the  os 
calcis,  the  front  of  the  foot  not  being  able  to  strike  the  ground,  owing 
to  the  weakness  of  the  gastrocnemius  muscles,  a  serviceable  operation 
has  been  devised  by  Whitman,  consisting  of  the  ablation  of  the  astrag- 
alus and  the  slipping  of  the  foot  backward,  so  that  the  weight  is 
borne  upon  the  middle  of  the  foot  instead  of  its  posterior  third.  A 
useful  foot  results,  the  ultimate  functional  result  being  excellent. 

Osteotomy  may  be  required  to  correct  severe  flexion  deformity  at 
the  hip.  and  at  the  knee  to  correct  the  knock-knee  and  flexion  at  the 
same  time.  At  the  hip  it  does  not  differ  from  the  ordinary  Gant 
operation,  and  is  necessary  only  in  cases  in  which  division  of  the  soft 
parts  is  not  enough  to  allow  sufficient  extension  of  the  thigh  on  the 
pelvis. 

At  the  knee  a  simple  transverse  division  of  the  femur  is  made 
just  above  the  condyles,  allowing  correction  of  both  flexion  and 
knock-knee  at  the  same  time.  These  operations,  of  course,  have  no 
effect  upon  the  paralysis  as  such,  but  merely  serve  to  place  the  limb 
in  a  position  suitable  for  weight-bearing.  After  operation  mechanical 
support  may  or  may  not  be  necessary. 

Excision. — In  other  cases  resection  of  joints  is  to  be  considered  on 
account  of  the  extreme  bony  deformity  which  they  present,  as  in  severe 
paralytic  knock-knee,  in  which  a  stiff  knee  rather  than  a  movable  one 
is  desired.  If  the  latter  is  preferable  an  osteotomy  rather  than  ex- 
cision should  be  done,  as  excision  leaves  a  stiff  joint.  The  deformity 
of  knock-knee  or  flexion  at  the  knee  can,  of  course,  be  corrected  by 
the  plane  of  the  bone  section  in  excision. 

AYrrv  Grafting. — It  has  been  shown  experimentally  on  animals 
that  it  is  possible  to  divide  and  transplant  a  motor  nerve  so  that  its 
efferent  impulses  are  transferred  from  its  own  peripheral  distribution 
to  that  of  the  nerve  into  whose  distal  part  it  is  transferred.  This 
has  been  applied  to  the  treatment  of  infantile  paralysis,  a  healthy  nerve, 
or  a  portion  of  one,  being  divided  and  sewed  to  the  cut  peripheral  end 
of  a  paralyzed  nerve.  Varying  degrees  of  success  have  attended  this 
procedure,  but  the  percentage  of  practical  failures  is  still  so  great  that 
the  method  cannot  be  regarded  as  having  passed  beyond  the  experi- 
mental stage. 


LfEFf-F','  OF 
LLEGE  GF  GGTEGF/^TK 


CHAPTER  XV. 

SPASTIC  AND   OTHER  PARALYSES. 

SPASTIC    PARALYSIS. 

THE  condition  is  known  under  the  following  names  :  Spastic  paral- 
ysis, cerebral  paralysis,  and  Little's  disease. 

Motor  disturbances  in  children  which  are  due  to  cerebral  lesions 
are  manifested  clinically  in  one  of  three  ways:  (i)  As  a  single 
hemiplegia;  (2)  as  a  diplegia;  (3)  as  a  paraplegia.  Contractures, 
choreiform  movements,  mental  impairment,  aphasia,  epilepsy,  inco- 
ordination,  etc.,  may  be  the  accompaniments  of  any  one  of  these 
forms. 

The  condition  is  rarely  congenital  and  most  frequently  acquired. 

CONGENITAL  SPASTIC  PARALYSIS. 

It  is  usually  not  recognized  at  birth,  as  it  consists  of  a  lack  of 
muscular  co-ordination  common  in  infancy,  which  persists  in  certain 
muscles  during  life.  The  origin  of  it  is  to  be  found  in  cerebral  defects, 
intra-uterine  cerebral  hemorrhage,  and  lack  of  development  of  the 
brain. 

NON-CONGENITAL  SPASTIC  PARALYSIS. 

Symptoms. — The  condition  may  follow  cerebro-meningitis  in  an 
acute  attack  with  cerebral  disturbances,  or  as  a  result  from  chronic 
hydrocephalus.  The  onset  may  resemble  very  closely  that  of  infantile 
spinal  paralysis;  it  often  begins  with  an  illness  of  some  sort.  Fre- 
quently paralysis  develops  in  the  course  of  an  infectious  disease,  some- 
times after  a  slight  feverish  attack,  sometimes  after  a  fall  or  a  slight 
blow  on  the  head.  It  frequently  is  caused  by  a  cerebral  hemorrhage 
occurring  in  difficult  labor.  Commonly  the  onset  is  marked  by  con- 
vulsions. Delirium  or  screaming  spells  may  accompany  the  onset. 

When  the  paralysis  is  noticed,  it  is  found  to  be  most  often  hemi- 
plegic  in  distribution.  Monoplegia  is  rare.  The  face  is  paralyzed  in 

301 


302  ORTHOPEDIC  SURGERY 

a  moderate  proportion  of  all  cases,  and  the  arm  is  generally  affected 
more  severely  than  the  leg  and  recovers  more  slowly.  The  facial 
paralysis  ordinarily  is  not  complete  and  disappears  first  of  all  the 
paralyses.  Strabismus  is  common;  the  reflexes  of  the  affected  side 
are  much  increased  from  the  first.  As  in  the  hemiplegia  of  adults, 
rigidity  of  the  affected  muscles  comes  on  in  about  seventy-five' 
per  cent  of  all  cases  at  a  varying  time  after  the  onset  of  the 
paralysis.  The  rigidity,  when  present,  is  increased  by  any  attempt 
to  use  the  limb;  it  is  excited  by  passive  manipulation  and  it  disappears 


FIG  266.— Case  of  Left  Hemiplegia 
Attempting  to  Walk. 


FIG.    267. — Attitude    in    Attempted    Walking, 
Spastic  Paraplegia. 


during  sleep  and  usually  under  an  anaesthetic.     Post-hemiplegic  move- 
ments follow  in  a  certain  proportion  of  cases. 

Mental  enfeeblement,  varying  from  complete  idiocy  to  simple  back- 
wardness, develops  in  a  large  proportion  of  all  cases.  The  mental 
disability  may  be  manifested  in  the  milder  cases  by  an  excessive  irri- 
tability and  a  disposition  to  do  mischief  and  perhaps  to  destroy  play- 
things wantonly.  Furious  outbursts  of  temper  are  not  uncommon. 


SPASTIC  AND  OTHER  PARALYSES  303 

The  mind  may,  however,  remain  perfectly  clear  in  spite  of  a  severe 
hemiplegia,  and  no  sign  of  mental  deterioration  may  be  present  in  the 
early  or  the  late  history  of  the  disease.  Such  children  as  escape  mental 
deterioration  in  childhood  may  develop  psychoses  later  in  life. 

Epileptic  attacks  appear  in  one-quarter  to  one-half  of  all  cases 
reported.  Ordinarily  they  come  on  in  two  or  three  years  after  the 
paralysis,  but  they  may  be  delayed,  and  ten  or  even  thirty  years  may 
elapse  sometimes;  on  the  other  hand,  they  may  begin  within  a  few 
weeks  of  the  onset. 

To  the  later  history  of  the  affection  belong  the  atrophy  and  con- 
tractions of  the  limbs.  In  hemiplegia  the  affected  side  rarely  recovers 


FIG.  268. — Severe  Infantile  Spastic  Paralysis. 

entirely,  and  often  the  growth  of  the  bones  may  be  retarded.  The 
muscular  atrophy,  as  a  rule,  is  not  so  great  as  in  infantile  spinal 
paralysis. 

The  permanent  contractions  that  come  on  are  most  noticeable  in 
the  arms,  legs,  and  feet.  The  arm  is  held  close  to  the  side,  the  elbow 
is  flexed  strongly  and  firmly,  the  hand  is  flexed,  and  the  fingers  are 
,  drawn  into  the  palm,  usually  embracing  the  thumb.  The  humerus 
is  rotated  inward,  and  outward  rotation  is  resisted  by  muscular  con- 
traction. Supination  and  extension  of  the  fingers  are  resisted. 

The  leg  in  bad  cases  is  adducted  and  flexed  at  the  hip,  the  ham- 
string muscles  of  the  knee  are  contracted,  and  flexion  of  the  knee 
results,  while  the  foot  is  in  a  position  of  talipes  equino-varus  or  simple 
equinus.  In  very  mild  cases  only  the  finer  movements  of  the  hand 
may  be  lost,  and  the  leg  movements  may  be  impaired  only  enough  to 
cause  a  limp. 


304 


ORTHOPEDIC  SURGERY 


Post-Paralytic  Disorders  of  More  incut. — In  certain  cases  of  hemi- 
plegia,  single  and  double,  a  disturbance  of  motion  occurs  at  a  later 


FIG.  269. — Severe   Spastic   Paralysis  with    Cross-legged    Progression   on   Attempted   Walking. 

stage,  which  is  spoken  of  under  many  different  names,  such  as  atheto- 
sis  and  chorea  spastica. 

Spastic  Condition  of  the  Muscles. — At  times  the  tonic  spasm  of 
the  muscles  becomes  the  most  prominent  feature  of  the  case,  and  there 
is  a  persistent  stiffness  and  constant  spasm  of  the  muscles  of  the  legs 
and  sometimes  of  the  arms;  the  legs  are  rigid,  and  the  feet  are  ex- 


SPASTIC  AND  OTHER  PARALYSES 


305 


tended,  and  when  an  attempt  is  made  to  walk  the  child  stands  on 
tiptoe,  and  often  the  spasm  of  the  adductor  muscles  is  so  great  that 
the  legs  are  crossed.  The  walk  is  almost  characteristic — a  clinging 
gait,  in  which  the  feet  are  scraped  along  the  floor  with  much  effort 
and  straining  at  every  step,  if  indeed  the  spasm  is  not  so  great  that 
walking  at  all  is  out  of  the  question. 

In  the  severest  cases  the  children  have  strabismus,  a  stupid,  idiotic 

face,  the  saliva  drips  from  the  mouth, 
and  the  teeth  decay  very  early.  In  the 
more  severe  cases  it  is  often  impossible 
to  demonstrate  the  increased  tendon  re- 
flexes either  at  the  knee  or  at  the  ankle 
on  account  of  the  great  stiffness  of  the 
legs,  because  the  muscles  are  contin- 
ually at  their  maximum  of  contraction. 
In  the  milder  cases  exaggerated  reflexes 
are  almost  constant.  The  electrical  re- 
action in  these  and  in  the  hemiplegic 
cases  is  unchanged. 

Pathology. — The  pathological  con- 
dition is  much  the  same  in  hemiplegia, 
diplegia,  and  paraplegia.  These  con- 
ditions in  general  are  due  to  embolism 
or  hemorrhage,  and  the  resulting  re- 
tardation of  growth  of  the  affected  por- 
tion of  the  brain,  together  with  the  sec- 
ondary changes  in  the  spinal  cord.  Au- 
topsies made  later  in  the  disease  show 
wasting  and  sclerosis  of  a  greater  or 
less  part  of  the  brain  and  the  condition 
known  as  porencephalus.  Porence- 
phalus  occurs  as  a  loss  of  substance  in 
the  form  of  cavities  or  cysts. 

The  pathology  of  the  condition  is  a 
lesion  of  the  motor  tract  of  the  brain 
with  consequent  atrophy  and  retarded 

development  of  the  affected  portion,  and  descending  degeneration  of 
the  pyramidal  tracts  and  lateral  columns  of  the  cord. 

Diagnosis. — Spastic  paraplegia  is  characterized  by  tonic  contrac- 
tion of  the  muscles  which  yields  to  steady  resistance,  except  in  the 
advanced  stages  where  fibrous  changes  have  taken  place.  The  galvanic 


FIG.  270. — Spastic   Paraplegia   in   an 
Adult. 


ORTHOPEDIC  SURGERY 

reaction  is  normal.  At  times  the  muscular  rigidity  is  so  excessive 
that  the  exaggerated  knee-jerk  and  ankle  clonus  cannot  be  obtained. 
In  estimating  the  child's  mental  condition,  very  little  weight  can  be 
attached  to  the  parents'  account  of  the  patient  s  capacity. 


FIG.  271. — Diseased  Brain  in  Case  of  Spastic  Paralysis. 

Prognosis. — The  prognosis  in  these  cases  should  be  most  guarded, 
and  is  dependent  upon  the  extent  of  the  central  lesion,  not  always 
easily  recognized.  \\  hen  marked  mental  impairment  is  present  little 
benefit  can  be  expected  from  surgical  treatment.  The  spastic  muscular 
condition  is  to  be  regarded  as  a  difficulty  in  addition  to  the  mental 
condition  which  especially  needs  treatment.  \Yhen  no  mental  impair- 
ment is  present  much  benefit  can  be  expected  from  suitable  surgical 
treatment. 

Treatment. — In  spastic  paralysis  the  treatment  will  be  considered 
under  the  following  heads:  (i)  Muscle  training  and  exercise;  (2) 


SPASTIC  AND  OTHER  PARALYSES 


307 


operative  lengthening  of  muscles,  tendons,  and  fasciae;    (3)   tendon 
transference;    (4)   alcohol  injections;    (5)   division  of  the  posterior 

nerve  roots  and  (6)  division  of 
those  fibres  of  the  motor  nerves 
supplying  the  contracted  muscles. 
In  spastic  paralysis  it  is  at  times 
possible  to  accomplish  much  by 
muscular  training  and  developing 
exercises.  The  muscles  which 
are  most  strongly  contracted  are 
the  thigh  adductors  and  the  calf 
muscles.  Such  a  patient  should 
be  given  exercises  calculated  to  de- 
velop the  abductor  muscles  and  the 
dorsal  flexors  of  the  foot,  which 
by  increased  power  will  in  a  meas- 
ure counterbalance  the  muscles 
which  are  too  powerful.  In  walk- 
ing the  patient  should  be  cautioned 
to  go  very  slowly,  to  lift  each  foot 
well  off  of  the  ground,  and  to  turn 
out  the  toes  with  much  care.  In 
connection  with  massage  and  rub- 
bing, this  method  of  treatment  is 
capable  of  accomplishing  much  in 
the  milder  cases. 

The     disappearance     of     the 
aphasia    is    aided    by    systematic 
training,  and  it  always  proves  more  tractable  than  in  the  adult. 

Apparatus  is  of  little  advantage  in  cerebral  paralysis  except  in  re- 
taining the  limbs  in  proper  position  after  operation.  Post-hemiplegic 
movements  are  at  times  relieved  by  placing  the  member  at  rest  for  some 
weeks  or  months  under  restraint,  and  contractions  of  the  wrist  may  be 
stretched  by  means  of  a  palmar  splint  hyperextending  the  wrist. 

OPERATIVE  TREATMENT. — Tenotomy,  Myotomy,  Fasciotomy, 
Tenotomy  (complete  division  and  plastic  tenotomy). — Clinical  evi- 
dence has  proved  that  tenotomy,  especially  of  the  tendo  Achillis,  in 
this  class  is  of  great  benefit  in  suitable  cases,  not  only  in  improved 
walking,  but  sometimes  in  improvement  of  the  general  condition  and 
diminution  of  the  general  irritability,  from  the  benefit  of  increased 
activity.  If  tenotomy  of  the  tendo  Achillis  is  done  in  cases  of  marked 


FIG.  272. — Spastic  Paralysis  before  Operation. 


308 


ORTHOPEDIC  SURGERY 


talipes  equinus  the  contraction  ceases,  and  though  the  strength  of  the 
muscle  is  not  lost  in  a  number  of  cases  which  have  been  watched  by  the 
writers  for  several  years,  there  is  occasionally  a  tendency  to  a  reappear- 


FIG.  273. — Spastic   Paralysis  after   Operation. 

anre  of  the  equinus  deformity.  Plastic  lengthening  of  the  tendo  Achil- 
lis  by  dividing  halfway  through  the  tendon  on  opposite  sides  at  different 
levels  and  then  pulling  the  two  halves  of  the  tendon  by  each  other 
is  in  the  writers'  opinion  to  be  preferred  to  complete  division  of  the 
tendon  on  account  of  the  danger  of  overcorrection  sometimes  seen. 
Division  of  the  hamstring  tendons  by  open  incision  should  be  done 
when  they  are  sufficiently  contracted  to  prevent  the  full  extension  of 
the  knee.  This  operation  is  preferable  to  subcutaneous  tenotomy  be- 


SPASTIC  AND  OTHER  PARALYSES 


309 


cause  it  offers  a  better  chance  to  divide  contracted  tissues  other  than 
tendons.  In  the  severer  cases  with  adductor  spasm  division  of  the 
adductor  tendons  is  also  of  benefit. 

Myotomy  and  Fasciotouiy. — In  resistant  and  severe  cases  not  only 
must  the  tendons  be  divided,  but  contracted  bands  of  fasciae  must  be 


FIG.   274.—  Two  Cases  of  Severe  Spastic  Paralysis  of  Different  Types. 

cut.  The  removal  of  portions  of  the  contracted  muscles  is  advisable 
in  the  most  marked  cases  in  order  permanently  to  weaken  such  mus- 
cles, e.g.,  in  extreme  adduction  of  the  legs  the  resection  of  the  ad- 
ductor muscles  may  be  of  permanent  value  and  in  marked  inversion 
of  the  feet  it  is  desirable  to  remove  a  strip  of  the  tensor  vaginae 
femoris.1 

1  Gibney  :   Am.  Journ.  Orth.  Surgery,  ii.,  i. 


3io 


ORTHOPEDIC  SURGERY 


After  the  operation  the  limb  is  to  be  fixed  in  an  overcorrected  posi- 
tion by  means  of  plaster-of-Paris  bandages  or  retentive  appliances 
for  several  weeks.  This  is  to  be  followed  by  muscle  training,  gradu- 
ally increasing  exercises,  with  limbs  held  by  ambulatory  retention  ap- 
pliance (similar,  as  a  rule,  to  what  are  to  be  used  in  infantile  paralysis) 
until  the  proper  muscular  balance  has  been  established,  when  appliances 
are  to  be  discarded. 

It  is  to  be  remembered  that  the  affection  is  not  strictly  a  paralysis, 
but  a  disability  from  imperfect  muscular  co-ordination,  increased  by 
muscular  contraction  in  certain  muscles.  The  treatment  consists  in 
not  only  restoring  the  muscular  balance,  but  in  muscle  training  to  re- 
establish the  proper  muscular  co-ordination.  Care  is  necessary  during 
the  process  of  muscle  training  with  apparatus  not  to  overstretch  the 
divided  tendons. 

Tendon  transference  has  been  recommended  in  this  affection,  espe- 
cially of  the  hamstrings  forward,  to  reinforce  the  lengthened  extensor 
curis  by  a  procedure  similar  to  what 
is  employed  in  poliomyelitis.  The  pro- 
cedure should  be  reserved  for  the  more 
severe  cases,  as  it  necessarily  results  in 
a  loss  of  muscle  balance. 

Ann  and  Hand. — Tendon  trans- 
ference, however,  is  of  great  advantage 
in  the  spastic  contraction  of  the  fore- 
arm. The  pronator  radii  teres  may  be 
converted  into  a  supinator,1  and  the 
carpal  flexors  may  be  converted  into 
carpal  extensors.  In  the  first  operation 
an  incision,  two  or  three  inches  long,  is 
made  in  the  middle  of  the  front  of  the 
forearm.  The  upper  and  lower  borders 
of  the  pronator  are  cleared  and  the  ten- 
don with  its  periosteal  attachment  is 
freed  from  the  radius.  The  tendon  is 
then  passed  through  the  interosseous 

membrane  close  to  the  radius  and  the  tendon  reinserted  on  the  outer 
side  of  the  radius,  if  possible  at  the  site  of  its  former  insertion;  if  not, 
at  a  new  roughened  place  on  the  radius. 

In  the  other  operation  -  the  flexor  carpi  ulnaris  is  divided  just 

1  A.  H.  Tubby:  Brit.  Med.  Journ.,  September  7,  1901. 

2  Robert  Jones  :  Tubby  and  Jones,  "  Surgery  of  Paralysis,"  London,  1903,  p.  225. 


FIG.  275. — Transplantation  of  the  Pro- 
nator Radii  Teres  in  Spastic  Paralysis 
of  the  Arm. 


SPASTIC  AND  OTHER  PARALYSES  311 

above  the  annular  ligament  and  inserted  into  the  tendon  of  the  ex- 
tensor ulnaris,  and  the  flexor  carpi  radialis  divided  at  the  same  level 
and  attached  to  the  radial  extensor.  A  later  method  is  described  by 
Tubby  1  in  which,  in  addition  to  transplanting  the  pronator  radii  teres, 
he  divides  the  flexor  carpi  radialis  at  the  junction  of  its  lower  and 
middle  third  and  attaches  it  to  the  radius,  and  the  distal  end  of  the 
tendon  is  attached  to  the  tendon  of  the  palmaris  longus.  If  the  prona- 
tor radii  teres  is  too  short  it  is  attached  to  the  flexor  carpi  radialis. 

Alcohol  Injection. — On  the  ground  that  the  muscular  irritability  is 
constantly  increased  by  active  irritative  impulses  arising  from  the 
cortical  motor  cells  it  has  been  possible  to  secure  the  temporary  isola- 
tion of  muscular  groups  by  the  injection  of  certain  nerve  trunks  with 
alcohol  (7080$),  thus  resting  the  affected  muscles.  The  nerve  is  ex- 
posed by  dissection.  For  adductor  spasm  one  exposes  and  injects 
the  obturator  nerve;  for  overaction  of  the  hamstrings  the  branches  of 
the  sciatic  supplying  these  muscles ;  for  the  gastrocnemius  the  internal 
popliteal  nerve;  and  for  the  anterior  tibial  group,  the  anterior  tibial 
nerve.2  In  the  experience  of  the  writers  permanent  benefit  has  not 
followed  this  procedure. 

Division  of  the  Posterior  Nerve  Roots. — The  operation  of  division 
of  the  posterior  nerve  roots  has  been  advocated  and  performed  on 
the  theory  that  the  cessation  of  afferent  impulses  will  give  a  period 
of  rest  to  the  irritated  centres.  A  laminectomy  is  done  and  several 
of  the  lower  posterior  nerve  roots  supplying  the  legs  divided  on  each 
side.  The  operation  is  not  to  be  regarded  as  curative  in  itself,  but 
simply  as  giving  a  period  of  relaxation  during  which  exercises  may  be 
begun  which  shall  bring  about  a  better  muscular  balance,  although 
satisfactory  results  have  been  reported  by  Forster  3  the  place  of  the 
operation  has  not  yet  been  firmly  established.  The  procedure,  in 
children,  is  not  without  danger  to  life. 

Division  of  certain  fibres  in  efferent  nerves,  as  proposed  by  Stoffel,4 
has  for  its  aim  the  incision  of  parts  of  the  muscular  branches  of 
nerve  trunks  which  run  to  contracted  muscles.  The  main  nerve  trunk 
is  exposed  and  the  muscular  branches  identified  as  they  leave  the  main 
nerve  trunk.  This  identification  is  verified  by  the  electric  needle  and 
a  portion  of  the  nerve  excised. 

Satisfactory  results  have  been  reported,  but  the  operation  is  too 
new  to  have  established  its  permanent  value. 

1  Tubby:  Deformities.  Including  Diseases  of  Bones  and  Joints,  1912,  ii.,  732. 

2  Allison  and  Schwab:  Am.  Journ.  Orth.  Surg.,  viii.,  i,  95. 

3 Forster:  Berlin  klin.  Wochenschr.,  1913,  L.,  1217. 

4 Stoffel:  Therap.  Monatsch.,  Berlin,  1912,  xxvi,  841. 


312 


ORTHOPEDIC  SURGERY 


There  are  certain  motor  disturbances  affecting  children  which 
come  under  the  notice  of  the  orthopedic  surgeon  so  frequently  that  a 
brief  mention  of  their  characteristics  deserves  a  place  here.  These 
affections  are : 

I.  Pseudo-hypertrophic  muscular  paralysis.     Progressive  muscular 
atrophy. 

II.  Hereditary  Icccmotor  ataxia,  obstetrical  paralysis. 

PSEUDO-HYPERTROPHIC    MUSCULAR   PARALYSIS. 

Pseudo-hypertrophic  muscular  paralysis  is  an  affection  of  the  mus- 
cular system  characterized  by  a  diminution  or  loss  of  the  functional 
energy  of  certain  muscles  and  an  abnormal  increase  in  their  size, 
which,  together  with  diminution  in  the  size  of  other  muscles,  is 
pathognomonic.  Modern  classification  places  the  affection  among  the 
progressive  muscular  atrophies. 

The  etiology  of  the  affection  is  not  known.     The  disease  develops 
usually  during  childhood,  and  affects  males  more  commonly  than  fe- 
males.     The   disease    is   more   apt   to 
occur  in  family  groups  than  in  isolated 
cases. 

The  pathological  condition  consists 
in  the  overgrowth  of  the  connective 
tissue  in  the  muscles  and  the  wasting 
of  the  muscular  substance  proper,  while 
a  deposit  of  fat  takes  place  to  a 
greater  or  less  extent.  Xo  constant  or 
characteristic  pathological  condition  is 
found  in  the  spinal  cord. 

The  first  symptoms  to  attract  atten- 
tion to  the  child's  condition  are  mus- 
cular feebleness  and  peculiarity  of  gait. 
Such  children  tire  very  easily  in  walk- 
ing and  they  have  especially  difficulty 
in  going  up  and  down  stairs.  They 
fall  often  and  in  rising  frcm  the 
ground  they  adopt  a  procedure  which 
is  one  of  the  most  characteristic 
features  of  the  disease.  Inasmuch 

as  on  account  of  muscular  weakness  they  cannot  straighten  the  back 
or  extend  the  knees  without  assistance,  they  rise  from  the  ground  by 


FIG.   276. — Kyphosis  in  Pseudo-hypertro- 
phic Paralysis. 


SPASTIC  AND  OTHER  PARALYSES  313 

climbing  upon  the  thighs,  which  they  extend  by  pushing  them  down 
with  the  hands,  using  the  muscles  of  the  arms  to  accomplish  what  the 
leg  and  back  muscles  cannot  do. 

In  walking  these  children  throw  the  centre  of  gravity  of  the  body 
well  over  each  leg  in  turn  as  it  supports  the  body-weight,  and  the  result 
is  a  waddle  more  or  less  marked.  They  may  stand  with  marked 
lordosis  of  the  lumbar  spine,  even  in  moderately  advanced  cases,  chiefly 
due  to  a  weakness  of  the  lumbar  muscles.  The  lordosis  disappears 
when  the  patient  sits  down  and  a  bowing  backward  of  the  whole 
vertebral  column  takes  its  place.  In  kneeling  on  the  hands  and  knees 
at  times  there  may  be  noticed  a  characteristic  saddle-shaped  depression 
of  the  back,  which  is  due  to  the  weakness  of  the  erector  spime  muscles. 
The  enlargement  of  the  muscles  is  usually  most  marked  in  the  calves 
of  the  legs.  The  affected  muscles  are  hard  and  resistant  to  the 
touch. 

Atrophy  of  some  of  the  muscles  of  the  upper  extremity  is  apt  to 
be  present.  The  scapular  muscles,  the  serrati,  the  latissimus  dorsi, 
and  the  pectoralis  major  are  often  wasted. 

Talipes  equinus  and  flexion  of  the  knees  and  hips  may  occur  from 
muscular  contraction.  Lateral  curvature  of  the  spine  may  follow,  and 
at  other  times  a  permanent  flexion  of  the  spine  occurs  from  weakness 
of  the  erector  spinae  muscles,  and  the  child  sits  bowed  forward.'  The 
late  stage  of  the  affection  is  characterized  by  a  helplessness  more  or 
less  complete. 

Neither  the  reflexes  nor  the  electrical  reactions  are  modified  in 
any  degree  until  the  muscles  have  reached  a  marked  stage  of  atrophy. 
Then  they  are  diminished  in  proportion  to  the  muscular  wasting,  and 
finally  they  are  lost.  Very  often  the  skin  over  the  affected  limb  is 
mottled  and  subject  to  vascular  changes,  indicating  some  vasomotor 
disturbance. 

The  prognosis  is  as  unfavorable  as  possible.  Recovery  is  all  but 
unknown,  and  arrest  of  the  disease  is  rare.  The  course  of  the  disease 
is  essentially  chronic. 

Treatment  is  practically  without  benefit,  and  there  is  no  reason  to 
believe  that  drugs  have  any  effect  in  retarding  its  progress.  Elec- 
tricity, massage,  and  gymnastics  are  sometimes  of  benefit  in  connection 
with  other  treatment.  Tenotomy  is  of  use  as  soon  as  the  heels  are 
drawn  up.  Often  walking  may  become  impossible,  chiefly  on  that 
account,  and  division  of  the  tendo  Achillis  on  both  sides  may  restore 
for  a  time  the  power  of  walking;  also  tenotomy  of  the  hamstring 
tendons  at  the  knee  may  be  indicated  in  severe  cases. 


314  ORTHOPEDIC  SURGERY 

PROGRESSIVE   MUSCULAR   ATROPHY. 

Progressive  muscular  atrophy  is  an  affection  characterized  by  a 
wasting  of  the  voluntary  muscles,  and  a  consequent  diminution  in 
their  power,  which  pursues  a  chronic  course  and  attacks  successively 
individual  muscles  and  groups  of  muscles. 

In  muscular  atrophy  as  it  occurs  in  children,  the  only  cause  as- 
signable is  a  congenital  tendency,  often  inherited.  Males  are  more 
often  affected  than  females,  and  the  time  of  onset  of  the  disease  is 
most  variable. 

Progressive  muscular  atrophy  has,  since  the  days  of  A  ran  and 
Duchenne,  been  subdivided  into  different  types. 

r.  In  the  Aran-Duchenne  type  the  atrophy  begins  oftenest  in  the 
small  muscles  of  the  hand,  spreads  to  the  forearm,  and  perhaps  the 
shoulders  and  back.  It  may  begin  in  the  muscles  of  the  thighs.  The 
atrophied  muscles  show  fibrillary  contractions,  and  the  reaction  of 
degeneration  is  present.  The  affection  has  a  pathology  and  is  of 
spinal  origin. 

2.  The  hereditary  form  is  of  the  same  general  type  as  the  pre- 
ceding.    It  is  very  unusual  and  may  occur  in  more  than  one  member 
of  a  family. 

3.  The  peroneal  form  or  leg  type  of  progressive  muscular  atrophy 
affects  in  most  cases  the  lower  extremities.  The  extensor  muscles  of 
the  toes  are  first  affected,  then  the  small  muscles  of  the  feet,  and 
finally  the  entire  leg.     Talipes  equinus  or  equino-varus  is  a  common 
result.     Sensory  changes  are  generally  present.     The  reflexes  in  the 
lower  extremities  may  be  diminished  or  lost  if  the  disease  is  sufficiently 
advanced.     The  electrical  reactions,  as  a  rule,  are  altered  both  quanti- 
tatively and  qualitatively.     Cases  of  club-foot  occurring  in  this  type 
may  be  successfully  operated  on. 

The  changes  in  the  muscles  consist  in  atrophy  of  the  fibres,  a  loss 
of  transverse  striation,  and  a  proliferation  of  the  nuclei.  Degenera- 
tions of  the  nerves  are  present,  but  changes  of  importance  in  the  spinal 
cord  have  not  been  established. 

4.  Erb's  type.    The  juvenile  form  of  progressive  muscular  atrophy 
is  very  rare  and  is  characterized  by  progressive  wasting  of  certain 
groups  of  muscles.     These  are  the  muscles  of  the  shoulder  girdle,  the 
upper  arm,  the  pelvic  girdle,  the  thigh,  and  the  back.     The  forearm 
and  leg  muscles  remain,  for  a  long  time  at  least,  intact.     There  are 
no  fibrillary  contractions,  no  reaction  of  degeneration,  and  no  sensory 
disturbances. 


SPASTIC  AND  OTHER  PARALYSES  315 

5.  The  Landouzy-Dejerine  type  or  the  facio-scapulo-humeral 
variety  occurs  at  times  in  children.  The  muscles  of  the  face  are  first 
affected  and  the  atrophy  spreads  to  the  shoulder  and  arm  muscles.  In 
exceptional  cases  this  type  may  begin  in  the  arms  or  legs.  The 
reaction  of  degeneration  and  fibrillary  twitching  are  never  present. 

The  medical  treatment  of  all  these  affections  is  hopeless.  When 
muscular  contractions  occur  tendons  should  be  cut  and  deformities 
rectified.  Rest  to  the  atrophied  muscles,  massage,  and  electricity  are 
useful. 

HEREDITARY   ATAXIA. 

Hereditary  ataxia,  known  also  as  family  ataxia  and  Friedreich's 
disease,  deserves  mention  as  a  serious  motor  disorder  which  is  some- 
times met  in  children.  It  is  dependent  upon  a  family  predisposition, 
but  is  not  often  directly  inherited,  but  more  commcnly  appears  in 
several  members  of  one  generation.  These  cases  are  rare. 

Aside  from  the  influence  of  a  congenital  tendency  the  cause  of 
the  disease  is  as  yet  unknown.  The  disease  develops  most  often  early 
in  life. 

In  examining  sections  of  the  cord  in  these  cases,  changes  are  found 
similar  to  the  lesion  of  locomotor  ataxia. 

The  symptoms  resemble  very  closely  those  of  locomotor  ataxia. 
The  patient  notices  a  feeling  of  weakness  and  uncertainty  in  walking, 
and  soon  it  becomes  apparent  to  others  that  the  motions  of  the  legs 
are  not  properly  co-ordinated.  The  feet  are  placed  wide  apart  in 
standing,  and  in  walking  the  gait  is  practically  that  of  locomotor 
ataxia.  The  movements  of  the  hands  become  irregular  and  inco- 
ordinate, and  a  jerky  irregularity  develops  in  the  movements  of  the 
head  and  neck,  so  much  so  that  it  may  assume  the  aspect  of  an  irregu- 
lar tremor.  Speech  may  also  be  impaired.  The  knee-jerk  disappears, 
but  the  plantar  reflex  remains.  Sensation  is  affected  in  varying  degrees 
in  different  cases,  and  trophic  disturbances  of  the  skin  are  not  present. 
As  a  rule  the  sphincter  muscles  are  not  affected.  Nystagmus  is  often 
present  and  the  Argyll-Robertson  pupil  is  absent. 

Deformities  are  apt  to  come  on  in  the  later  stages  of  the  disease, 
lateral  curvature  may  be  present,  talipes  equinus  or  equino-varus, 
and  permanent  flexion  of  the  knee  are  likely  to  occur.  The  disease 
is  essentially  progressive,  and  the  prognosis  is  bad  in  proportion  to 
the  rapidity  of  progress. 

The  treatment  should  be  similar  to  that  in  common  use  in  loco- 
motor  ataxia.  Deformities  should  be  corrected  by  tenotomy,  etc.,  as 
they  occur. 

Among  similar  affections  is  the  cerebellar  type  of  hereditary  ataxia 


3i6  ORTHOPEDIC  SURGERY 

described  by  Marie,  differing  chiefly  in  having  exaggerated  reflexes 
and  ocular  symptoms  in  addition  to  those  described  above. 

OBSTETRICAL   PARALYSIS. 

Obsterical  paralysis  of  the  shoulder  is  an  affection  which  is  fairly 
common  and  most  often  results  in  a  disabled  arm.  It  occurs  generally 
after  difficult  labors  when  traction  is  made  upon  the  head  in  head 
presentations,  or  upon  the  trunk  when  the  head  is  delivered  last.  It 
may  occur,  however,  after  normal  labors. 

The  injury  appears  to  be  due  to  injury  to  the  two  upper  roots  of 
the  brachial  plexus,  the  muscles  chiefly  involved  being  the  biceps, 
deltoid,  and  supinators  of  the  forearm. 

In  certain  of  the  older  cases  there  is  to  be  found  a  downward  and 
forward  curve  of  the  tip  of  the  acromion  process  and  associated  with 
this  is  a  posterior  subluxation  1,  ~,  "'  of  the  head  of  the  humerus  which 
limit  abduction  and  external  rotation  of  the  arm.  \Yhether  this  is  a 
primary  condition,  the  result  of  a  trauma  received  at  birth,  or  a  second- 
ary deformity,  due  to  disuse  of  the  arm,  is  not  settled. 

The  condition  is  made  manifest  immediately  after  birth  by  an 
inability  to  use  one  arm ;  it  hangs  powerless  at  the  side,  with  the  palm 
turned  backward,  and  often  the  fingers  are  flexed  tightly.  If  the 
arm  is  lifted  from  the  side  it  falls  lifelessly  back  into  place,  and  al- 
though movement  of  the  fingers  is  generally  present,  it  is  impossible  to 
use  the  arm  to  any  extent  on  account  of  the  paralysis  of  the  shoulder 
muscles. 

If  the  arm  is  allowed  to  remain  hanging  in  this  position  during 
growth  the  adaptive  changes  resulting  simulate  very  closely  congenital 
dislocation  cf  the  shoulder. 

Three  types  are  recognized,  the  upper  arm,  lower  arm,  and  entire 
arm  types. 

The  prognosis  in  the  severer  cases  is  not  good  as  to  recovery. 

Treatment. — For  the  treatment  of  the  newborn  the  arm  should 
be  kept  in  a  sling  at  an  angle  from  the  side,  checking  the  tendency 
to  adduction  of  the  limb.  An  axillary  pad  or  splint  should  be  used, 
accompanied  by  measures  to  stimulate  the  circulation — massage,  gentle 
passive  exercises.  If  the  arm  and  hand  are  affected  the  tendency  to 
pronation  is  to  be  checked. 

In  older  cases  of  confirmed  contraction  the  arm  should  be  treated 

1  Fairbank  :  Lancet.  May  3.  1913. 

'  Lange :  Munch,  med.  YVochenschr..  1912,  Xo.  26.  U2I. 
*  Thomas.  T.  T. :  Annals  of  Surgery,  Feb.,  1914,  lix..  Xo.  2. 


SPASTIC  AND  OTHER  PARALYSES  317 

on  the  same  principles  that  are  of  use  for  the  contractions  of  cerebral 
paralysis  elsewhere;  viz.,  myotomy  and  fixation  for  a  time  in  an  over- 
corrected  position,  followed  by  muscle  training. 

Resection  of  the  affected  nerves  and  the  surrounding  cicatrix  in 
the  cervical  plexus  has  been  employed,  but  the  method  of  myotomy, 
overcorrection,  and  muscle  training  has,  as  a  rule,  given  better  func- 
tional results. 

Ischaemic  Paralysis. — Also  known  as  Volkmann's  paralysis,  as  first 
described  by  him,  is  a  condition  of  disability  of  the  forearm  following 
fracture  at  the  elbow  and  the  pressure  of  retaining  splints;  sometimes 
also  the  prolonged  use  of  an  Esmarch  tourniquet. 

The  affection  consists  of  a  myositis,  due  to  a  temporary  ischsemia, 
resulting  in  the  severe  cases  in  a  fibrous  degeneration  of  the  muscles, 
the  nerves  being  compressed  by  cicatricial  contraction. 

Sensory  and  motor  paralysis  results  with  flexion  and  contraction 
of  .the  wrist  and  fingers,  with  disturbances  of  the  circulation  in  the 
hand  and  atrophy. 

The  treatment  consists,  in  the  milder  early  cases,  in  measures  to 
stimulate  the  circulation;  but  in  the  severe  cases  operative  interfer- 
ence is  necessary.  This  consists  in  correcting  the  contractions  by 
myotomy  and  fasciotomy,  by  freeing  by  dissection  the  median  nerve 
if  compressed  by  contracted  tissue.  In  the  more  obstinate  cases  im- 
proved function  has  been  obtained  by  shortening  the  bones  of  the 
forearm,  removing  a  section  of  bone,  and  in  this  way  relieving  the 
tension  of  the  muscles. 

Method  of  Robert  Jones.1 — He  cuts  out  of  zinc  or  sheet  iron  five 
solints  which  will  fit  the  patient's  fingers  when  extended.  An  assist- 
ant then  fully  flexes  the  wrist  and  forcibly  holds  it  flexed.  This 
relaxes  the  fingers  and  each  one  is  separately  splinted.  The  wrist  is 
now  released  and  the  patient  is  told  to  extend  his  hand  systematically. 
In  a  few  days  the  extension  has  increased  so  much  that  it  is  possible 
for  a  splint  to  be  applied  from  the  finger-tins  to  the  wrist- joint,  the 
wrist  being  fully  flexed  to  allow  this  being  done.  The  second  splint 
is  applied  over  the  finger  splints.  The  hand  is  now  exercised  for 
several  days  so  that  extension  is  increased  and  a  third  splint  is  applied 
over  the  other  two,  extending  from  the  finger-tips  to  the  elbow  and 
is  altered  gradually  at  intervals  until  the  wrist  can  be  fully  extended. 
This  position  is  maintained  for  some  weeks  until  the  power  of  con- 
traction has  been  overcome,  after  which  the  splints  are  left  off  and  the 
hand  massaged. 

1  Jones:  Am.  Jour,  of  Orthopedic  Surgery,  1908,  v.,  377. 


CHAPTER  XVI. 

FUNCTIONAL  AFFECTIONS  OF  THE  JOINTS. 

UNILATERAL   ASYMMETRY. 
FUNCTIONAL  AFFECTIONS  OF  THE  JOINTS. 

FUNCTIONAL  or  netiromimetic  or  hysterical  are  names  applied 
to  a  class  of  joint  affections  where  there  is  no  evidence  of  organic 
disease,  yet  where  active  disability  exists. 

Etiology  and  Occurrence. — At  present  one  recognizes,  however, 
certain  cases  largely  in  emotional  women  and  children  where  excessive 
pain  and  symptoms  exist  without  demonstrable  organic  lesions,  and 
again  in  the  same  class  of  patients,  pain  and  symptoms  of  a  severe 
character  accompanying  organic  lesions  of  a  slight  grade.  Trauma 
and  an  antecedent  organic  lesion,  such  as  a  synovitis,  are  the  com- 
monest exciting  causes,  but  the  affection  occasionally  arises  apparently 
without  assignable  cause. 

Symptoms. — The  symptoms  are  generally  much  the  same  as  those 
of  an  organic  lesion  of  the  same  joint.  Pain,  lameness,  muscular  irri- 
tability, and  spasm,  the  slight  atrophy  of  disuse  and  malpositions  are 
the  accompaniments  of  the  affection.  But  the  subjective  signs  are 
out  of  proportion  to  the  objective,  and  are  fluctuating  and  inconsistent 
with  each  other.  Muscular  spasm,  for  example,  relaxes  when  the 
patient's  attention  is  diverted,  and  the  pain  and  lameness  are  not  only 
variable  but  are  out  of  all  proportion  to  any  demonstrable  organic 
cause. 

The  stigmata  of  hysteria  may  or  may  not  be  present  when  an 
organic  lesion  exists  or  has  existed;  the  subjective  symptoms  are  out 
of  proportion  to  the  cause,  and  in  many  cases  are  to  be  classed  as 
"  habit  pains."  The  cases  of  mixed  organic  and  functional  char- 
acter are  the  most  difficult  to  handle.  The  purest  type  of  hysterical 
joint  affection  is  seen  in  girls  just  at  or  before  puberty,  where  symp- 
toms of  excessive  pain,  lameness,  and  malposition  exist  in  the  hip, 
knee,  or  ankle,  e.g.,  without  demonstrable  organic  cause. 

Diagnosis. — The  diagnosis  is  a  dangerous  one  to  make,  and  should 

318 


FUNCTIONAL  AFFECTIONS  OF  THE  JOINTS          319 

be  formulated  only  after  the  most  painstaking  and  thorough  exam- 
ination, eliminating  all  organic  causes.  The  lines  on  which  it  should 
proceed  have  been  indicated  above. 

Prognosis. — The  prognosis  in  recent  cases  is  favorable,  and  in 
cases  of  longer  standing  is  less  favorable  in  those  where  the  duration 
has  been  long  and  in  those  where  the 
neurasthenic  or  hysterical  condition  is 
marked. 

Treatment. — The  treatment  con- 
sists first  in  the  general  improvement 
of  the  patient's  mental  and  physical 
condition,  and  generally  removal  from 
home  conditions  is  necessary  for  the 
re-education  of  the  patient,  in  which 
the  treatment  largely  consists.  The 
surgeon  must  be  sure  of  his  diagnosis, 
because  no  success  will  follow  a  treat- 
ment formulated  to  cover  either  a  func- 
tional or  organic  lesion,  and  temporiz- 
ing is  fatal  to  a  successful  issue. 

The  second  part  of  the  treatment 
consists  in  correcting  malpositions  if 
they  exist  by  traction,  manipulation  un- 
der ether,  or  by  apparatus,  and  then 
beginning  with  the  progressive  use  of 
the  affected  joint  without  regard  to  the 
increase  of  pain  caused.  This  course 
is  pursued  until  the  normal  use  of  the 
joint  is  regained.  Massage,  exercises, 
and  similar  measures  to  restore  the  cir- 
culation and  muscles  of  the  affected 
joint  are  of  use.  The  prolonged  use 
of  apparatus,  crutches,  etc.,  is  unde- 
sirable. In  cases  of  long  standing 
tenotomy  may  be  required  to  correct 
malpositions. 

Functional  affections  of  the  especial  joints  are  sufficiently  well 
covered  by  the  general  description ;  but  the  spine  requires  separate 
mention,  both  as  to  symptoms  and  treatment. 


FIG.  277. — Attitude  in  Wa'.hing  in  a 
Case  of  Hysterical  Affection  of  the 
Joints  of  the  Leg  in  a  Girl  of 

Thirteen. 


320  ORTHOPEDIC  SURGERY 

FUNCTIONAL  AFFECTIONS  OF  THE  SPINE. 

This  condition  is  described  under  the  names  of  irritable  spine, 
spinal  irritation,  neuromimesis  of  the  spine,  hysterical  spine,  weakness 
of  the  spine,  the  term  backstrain  is  probably  more  correct. 

Etiology  and  Occurrence. — The  affection  occurs  frequently,  is  un- 
common in  children,  and  affects  adolescent  and  young  adult  women 
more  often  than  men  or  than  older  persons.  Patients  affected  by  it 
are  generally  of  less  than  the  average  physique  and  resistance,  and 
are  most  often  of  the  emotional,  neurasthenic,  or  excitable  tempera- 
ment. 

The  condition  frequently  follows  trauma,  either  severe  or  slight, 
overuse  or  overstrain  of  the  back  muscles,  or  it  may  occur  apparently 
spontaneously. 

Symptoms. — The  symptoms  are  irritability,  pain,  and  sensitiveness 
in  the  spine,  generally  aggravated  by  standing,  walking,  forward  bend- 
ing, and  sometimes  by  sitting.  The  pain  and  irritability  frequently 
extend  into  the  buttock  and  thighs.  The  lower  part  of  the  back  is 
more  frequently  affected  than  the  upper,  and  pain  and  tenderness  in 
one  or  both  sacro-iliac  joints  is  a  frequent  symptom.  It  may  be 
accompanied  by  hypenesthesia  of  the  skin,  and  muscular  irritability 
and  spasm  are  frequently  found  in  the  erector  spinae  muscles. 

The  condition  varies  from  a  degree  where  there  is  occasional 
moderate  backache  after  exertion  through  all  grades  to  a  condition 
where  the  patient  is  bedridden  and  helpless,  an  instance  of  the  "  spinal 
invalid."  This  spinal  affection,  although  not  strictly  organic,  yet 
seems  to  have  a  definite  mechanical  basis.  In  the  erect  standing  posi- 
tion the  weight  of  the  body  is  held  from  falling  forward  by  the 
posterior  muscles,  which  for  this  purpose  are  all  stronger  than  the 
anterior,  e.g.,  the  gastrocnemius  is  far  larger  than  all  the  anterior 
muscles  combined.  Under  conditions  of  general  muscular  laxity  and 
other  disturbances,  which  we  do  not  now  understand,  the  strain  thrown 
upon  the  posterior  muscles  of  the  back  and  thighs  is  increased,  and 
undue  overstrain,  pain,  tenderness  and  irritability  develop  in  the  mus- 
cles, fasci?e  and  joints  of  the  lower  back,  pelvis,  buttocks,  and  thighs. 
Hence  the  lumbar  and  sacral  pains,  the  pain  and  tenderness  in  the 
sacro-iliac  joints  and  thighs  (so  often  classed  as  sciatica),  and  the 
less  frequent  pain  in  the  dorsal  spine  and  back  of  the  neck.  On 
inspection  such  patients  most  often  show  a  "  slumped  "  relaxed  posi- 
tion of  the  spine,  with  rounded  dorsal  and  flattened  lumbar  region. 
On  the  other  hand,  others  stand  with  a  slight  lateral  curve,  in  which 


FUNCTIONAL  AFFECTIONS  OF  THE  JOINTS          321 

case  the  pain  is  most  often  unilateral  and  on  the  convex  side  of 
the  body,  but  as  a  rule  of  the  same  general  character  as  that  described. 
Certain  cases  are  associated  with  static  troubles  in  the  feet  or  intra- 
pelvic  disease  or  malposition. 

A  preceding  trauma  may  or  may  not  be  found  in  the  history,  as 
for  example  the  post-operative  backache  following  the  stretching  of 
the  lumbar  muscles  in  certain  operations;  the  traumatic  cases,  as  a 
rule,  present  more  stiffness  of  the  spine,  and  have  already  been  spoken 
of  under  spinal  sprains. 

Diagnosis. — The  diagnosis  of  the  condition  consists  in  the  elimina- 
tion of  organic  spinal  disease,  such  as  tuberculosis  and  arthritis  de- 
formans  of  the  spine.  If  intrapelvic  disease  or  malposition  exists  it 
is  a  competent  cause  of  the  symptoms  described.  After  the  careful 
elimination  of  all  these  factors  a  functional  disorder  may  be  assumed 
to  exist,  presumably  largely  of  mechanical  origin. 

Prognosis. — The  condition  is  notoriously  resistant  to  treatment, 
and  the  outlook  is  least  favorable  in  cases  of  long  standing,  associated 
with  marked  neurasthenia,  especially  if  no  obvious  mechanical  defect 
exists.  It  is  most  favorable  in  recent  cases,  with  a  demonstrably  bad 
standing  position  and  absence  of  marked  neurasthenia.  Under  these 
conditions  in  patients  of  average  resistance  a  cure  should  be  generally 
effected. 

Treatment.1 — The  treatment  should  be  directed  to  the  cause  of  the 
condition,  namely,  the  backstrain.  The  back  muscles  being  irritable 
and  overstrained,  should  first  be  rested  in  the  severest  cases  by  recum- 
bency for  part  or  all  of  the  time,  with  the  hollow  of  the  back  sup- 
ported. In  the  standing  position  a  jacket,  brace,  or  corset  should  be 
worn  at  first,  when  the  muscles  are  irritable  and  weak,  to  splint  the 
back  and  relieve  the  overstrained  muscles.  A  tight  pelvic  band  is 
generally  comfortable,  probably  acting  as  an  annular  ligament  to  the 
glutei  and  pelvic  femoral  muscles.  Exercises  to  cultivate  a  correct 
standing  position  are  the  real  means  of  cure,  and  should  be  begun 
very  gently,  with  the  aim  of  inducing  a  correct  standing  position;  and 
massage  is  of  value,  given  in  moderation  and  not  too  early.  If  a  short 
leg  exists  in  connection  with  lateral  deviation  it  should  be  corrected  by 
increased  thickness  of  the  sole.  The  general  condition  should  of 
course  receive  attention. 

UNILATERAL   ASYMMETRY. 

Apart   from  pathological  conditions  causing  asymmetry  in  cor- 
responding bones  on  the  two  sides,  difference  in  the  length  of  cor- 
1  Reynolds  and  Lovett:  Jour.  A.  M.  A.,  May  23,  1914. 


322  ORTHOPEDIC  SURGERY 

responding  bones  in  healthy  individuals  is  apparently  the  rule,  perfect 
symmetry  being  exceptional.  In  the  arms  this  difference  is  of  no 
importance,  but  in  the  bones  of  the  leg  leads  to  slight  obliquity  of 
the  pelvis  and  consequent  curving  of  the  spine  to  one  side  in  the 
standing  position.  It  has  been  shown  by  observation  that  in  healthy 
boys  something  more  than  half  show  a  difference  in  the  length  of  the 
legs  of  from  J/£  inch  to  \l/>  inches.1  The  conventional  measurement 
from  the  anterior  superior  pelvic  spine  to  the  malleolus  is  unreliable, 
because  of  the  uncertainty  of  the  bony  landmarks,  because  of  the 
variations  in  the  positions  of  the  anterior  superior  spines  in  the  pelvis, 
and  because  it  does  not  take  into  account  pelvic  asymmetry.  So  far 
as  the  spine  is  concerned,  the  equal  length  of  the  legs  can  be  ascer- 
tained by  building  up  the  short  leg  by  a  series  of  pamphlets  placed 
under  the  foot  until  the  anterior  superior  iliac  spines  are  level  and  the 
spine  is  in  the  middle  line  of  the  body.  Inferences  drawn  from  other 
methods  are  likely  to  be  misleading. 

Long  continued  pain  in  the  back  and  hip,  generally  unilateral,  may 
be  due  to  the  shortness  of  one  leg,  and  is  relieved  by  its  correction. 

Hypertrophy  of  one  member,  or  part  of  one  member,  of  very 
marked  degree  may  occur  as  the  result  of  dilatation  of  the  blood 
vessels  (angioma),  from  disease  of  the  lymphatics  (multiple  plexiform 
fibroma),  and  as  the  result  of  congenital  anomalies. 

1  Morton  :  Phila.  Med.  Times,  July  10,  1886. 


CHAPTER  XVII. 

CONGENITAL  DISLOCATIONS. 

CONGENITAL  DISLOCATION   OF  THE  HIP. 

CONGENITAL  dislocation  of  the  hip  is  neither  a  common  affection 
nor  one  of  very  great  rarity.  Among  6,969  orthopedic  patients  apply- 
ing at  the  out-patient  department  of  the  Children's  Hospital,  there 
were  152  cases  of  congenital  dislocation  of  one  or  both  hips. 

The  affection  is  much  more  common  in  girls  than  in  boys;  girls 
present  88  per  cent  of  the  cases  of  the  deformity.  No  satisfactory 


FIG.  278. — Congenital    Dislocation   of   the   Hip   in    Full-term   Foetus.      (Warren   Museum.) 

explanation  has  been  advanced  to  account  for  this  preponderance  in 
girls. 

Etiology. — The  etiology  of  the  affection  is  not  known.  True 
congenital  dislocation  without  doubt  is  an  affection  of  uterine  life, 
congenital  dislocations  having  been  found  in  the  foetus.  It  would 
seem  also  that  it  is  not  an  arrest  of  development  like  harelip,  but,  like 
congenital  club-foot,  rather  a  perversion  of  it,  a  malposition  of  bones 

323 


324 


ORTHOPEDIC  SURGERY 


with  the  resulting  structural  changes  of  the  soft  parts.  Violence  at 
birth  alone  is  not  considered  the  cause  of  true  congenital  dislocation. 

In  a  few  instances  there  appears  to  be  an  hereditary  influence,  and 
in  other  cases  two  children  of  the  same  family  have  been  afflicted 
with  the  affection.  This  is,  however,  not  the  rule. 

Pathology. — The  changes  in  the  anatomical  structures  seen  in 
congenital  dislocation  are  found  in  the  capsule,  in  the  muscles,  and  in 


FIG.  279. — Congenital  Dislocation,  Child  of  Ten.  Femur  sawn  and  sides  reflected,  showing 
dislocated  position  of  the  femoral  head,  the  capsular  pouch,  the  capsular  hymen  in  front  of  the 
acetabulum,  the  acetabular  cavity, and  capsular  constriction  at  the  mouth.  (Warren  Museum.) 

the  bones.  The  changes  in  the  capsule  are  such  as  would  naturally 
follow  a  prenatal  dislocation  before  the  joint  structures  were  formed. 
Normally  the  capsule  passes  from  the  rim  of  the  acetabulum  to  the 
neck  of  the  femur,  the  head  being  placed  well  in  the  socket  and  held 
firmly  by  the  cotyloid  ligament.  In  congenital  dislocation,  when  the 
head  lies  out  of  the  socket  and  above  the  acetabulum,  the  capsule  is 
stretched.  Furthermore,  the  weight  of  the  body,  as  soon  as  the  indi- 
vidual walks,  rests  not  on  the  bead  of  the  femur  placed  under  the 
acetabulum,  but  falls  upon  the  capsule,  which  stretches  like  a  strap 
from  the  acetabulum  to  the  trochanter,  and  this  capsule  necessarily 
becomes  thickened.  As  it  is  stretched  across  the  acetabulum  it  be- 
comes adherent  at  the  rim  and  to  a  portion  of  the  ilium,  so  that  the 


CONGENITAL  DISLOCATIONS  325 

acetabulum  seems  obliterated,  being  covered  by  thick,  strong,  fibrous 
tissue,  reaching  from  rim  to  rim.  This  portion  of  the  capsule  is 
entirely  shut  off  by  adhesion  from  that  which  surrounds  the  head, 
save  for  a  small  opening  at  the  upper  portion  of  the  rim.  This  open- 
ing may  be,  and  usually  is,  in  older  cases,  smaller  than  the  head,  and 


FIG.  --So. — Femur  in  Congenital  Dislocation,  Showing  Alteration  in  Angle  of  Neck. 

not  easily  stretched,  as  the  tissues  lose  their  elasticity  owing  to  the 
fibrous  bands  which  form  from  the  use  of  the  capsule  as  a  weight- 
bearing  structure. 

In  the  infantile  cases  the  capsule  is  loose  and  there  is  a  lack  'of 
development  of  the  cartilaginous  prolongations  of  the  rim  of  the 
acetabulum  and  of  the  cotyloid  ligament. 

The  muscles  are  changed  in  consequence  of  the  altered  position 
of  the  head.  Some  of  the  muscles  are  shortened,  others  are  length- 
ened. The  muscles  which  are  shortened  are  the  adductor  group,  the 
psoas  and  iliacus,  and  the  muscles  reaching  from  the  tuberosity  of 


326 


ORTHOPEDIC  SURGERY 


the  ischium  to  the  leg,  i.e.,  the  hamstring  muscles.     The  alteration  in 
the  bone  consists  of  a  flattening  or  alteration  of  the  shape  of  the 


FIG.  281. — Old   Congenital   Dislocation   of   Hip  with    Alteration   of  Neck   of   Femur  to   Shape  of 
Acetabulum.      (Warren  Museum.) 

head,  a  twist  of  the  neck  (the  consequence  of  malposition  of  the 
head),  and  in  the  shape  of  the  acetabulum,  which  is  sometimes  tri- 
angular in  shape  and  shallow. 

Lcmcj  axis  neck. 


Transverse 
axis  condijlea. 


FIG.  282. — Twist  of  Xeck  in  Congenitally  Dislocated  Femur,   Looking  from  Above  Downward. 

If  the  point  of  suspension  is  directly  over  the  proper  place  for  the 
acetabulum,  the  patient's  pelvis  is  hung  in  a  comparatively  normal 
plane,  but  if  much  behind  it,  the  pelvis  is  tilted  and  severe  lordosis 
results,  the  latter  being  the  more  common  condition. 


CONGENITAL  DISLOCATIONS 


327 


Symptoms. — The  deformity  often  attracts  no  attention  until  the 
child  learns  to  walk.  Then,  in  double  cases,  it  is  noticed  to  stand 
ordinarily  with  its  back  very  much  arched  and  to  waddle  most 


FIG.  283. — Unilateral  Dislocation  of  the 
Hip.      (Fiske   Prize  Fund   Essay.) 


FIG.  284. — Prominence  of  Trochanters  in 
Double  Congenital  Dislocation  of  the 
Hip.  (Fiske  Prize  Fund  Essay.) 


markedly  when  walking  is  well  begun.  This  is  characteristic  and  very 
marked.  When  the  dislocation  is  only  unilateral,  the  gait  becomes  an 
exaggerated  limp ;  in  stepping  on  the  leg  the  child  leans  to  the  af- 
fected side,  and  the  leg  seems  to  have  grown  shorter.  In  double 
dislocation  in  young  children,  the  prominence  of  the  trochanters  is 
not  marked  enough  to  attract  attention ;  in  older  persons,  however,  the 
prominence  of  the  trochanters  is  most  noticeable.  There  is  no  com- 
plaint of  pain  by  children  suffering  from  this  affection. 

Diagnosis. — The  diagnosis  is  not  difficult  in  children  who  are  old 
enough  to  walk.     The  limp  is  characteristic.     There  is  shortening  of 


328  ORTHOPEDIC  SURGERY 

the  limb.  On  palpation  the  trochanter  is  high,  and  the  head,  except 
in  large,  plump  children,  can  be  felt  above  and  behind  its  normal 
place. 

On  pulling  the  leg  with  gentle  force  the  trochanter  will  be  felt 
in  younger  cases  drawn  down,  if  the  other  hand  is  placed  upon  it, 
and  to  slip  back  when  the  leg  is  released,  and  a  measurement  will 


FIG.  285.- — Coxa  Yara,  Showing  Elevation 
of  Pelvis  when  Patient  Stands  on  Af- 
fected Limb. 


FIG.  286. — Cong.ir'tal  Dislocation,  Showing 
Dropping  of  Pelvis  when  Patient  Stands 
on  the  Affected  Limb. 


show  that  the  leg  has  been  lengthened  temporarily  by  the  traction 
force. 

The  muscles,  although  not  normally  developed,  are  not  paralyzed, 
and  the  children  are  healthy.  In  unilateral  dislocation  the  leg  of  the 
affected  side  is  slightly  smaller  than  the  other. 

In  larger  children  and  adults  the  conformation  and  outline  of  the 
hips  are  so  distinctive  that  the  diagnosis  may  be  made  almost  at  a 


CONGENITAL  DISLOCATIONS 

glance;  but  in  young  children  palpation  or  a  skiagraphic  examination 
is  often  necessary. 

Trendelenburg  has   called   attention   to   an   important   diagnostic 
symptom.     When  a  normal  child  stands  upon  either  limb  and  flexes 


FIG.  287. — Lordosis  in  Double  Congenital 
Dislocation  of  the  Hip.  (Fiske  Prize 
Fund  Essay.) 


FIG.  288.— Broadening  the  Peri- 
neum in  Double  Congenital  Dis- 
location of  the  Hip.  (Fiske 
Prize  Fund  Essay.) 


the  other  at  the  knee  and  thigh,  the  opposite  buttock  will  be  seen  not 
.to  drop.  In  the  case  of  congenital  dislocation  of  the  hip,  however, 
the  opposite  buttock  will  be  found  to  drop  to  a  noticeable  degree  if 
the  patient  takes  this  attitude.  This  is  to  be  explained  by  the  fact  that 
in  congenital  dislocation  of  the  hip,  owing  to  the  fact  that  the  head 
of  the  femur  is  not  in  the  socket,  the  muscles  from  the  great  tro- 
chanter  and  the  pelvis  (which  serve  to  keep  the  pelvis  level)  when 
supported  on  one  side  have  no  purchase  and  are  therefore  inefficient. 
A  skiagraphic  picture  is  of  great  value  in  diagnosis,  and  if  accurate 
is  conclusive. 


330 


ORTHOPEDIC  SURGERY 


Coxa  vara,  or  the  distortion  of  the  neck  of  the  femur,  which 
shortens  the  limb  and  raises  the  trochanter  above  Xelaton's  line,  may 
be  confounded  with  congenital  dislocation.  The  mistake  can  be 
avoided  if  the  fact  is  borne  in  mind  that  in  coxa  vara  the  head  is  in 
its  normal  socket,  while  in  congenital  dislocation  the  head  is  to  be 
felt  outside  of  the  acetabulum. 

Prognosis. — The  disability  caused  by  this  affection  in  childhood  is 
slight,  but  the  limp  is  noticeable,  and,  in  double  congenital  dislocation, 


89. — Double   Congenital    I)isloca;ion    Unreduced. 

may  be  distressing.  In  single  dislocation  the  defect  in  adults  may 
entail  only  an  inability  to  engage  in  active  occupation,  accompanied 
by  occasional  attacks  of  severe  muscular  pain,  with  muscular  cramps. 
These  attacks  subside  under  rest,  but  if  the  patient  becomes  heavier 
or  feeble  they  may  necessitate  the  use  of  crutches  and  cause  severe 
disability.  Muscular  patients  suffer  less  than  those  with  feeble  mus- 
cles. In  double  dislocation  the  trouble  is  increased. 

Treatment. — In  a  few  instances  of  congenital  dislocation  of  the 
hip  seen  in  infants  under  one  year  of  age,  a  spontaneous  recovery  has 
been  observed,  but  in  other  cases  operative  treatment  is  needed. 

In  a  majority  of  cases  manipulative  reduction  under  an  anaesthetic 
is  the  method  to  be  employed. 


CONGENITAL  DISLOCATIONS  33* 

MANIPULATIVE  REDUCTION. 

There  are  several  manipulative  methods  employed,  all  based  upon 
the  plan  of  stretching  the  contracted  soft  parts,  muscles,  capsule  and 
ligaments,  so  that  the  head  can  be  forced  successfully  through  the 


FIG.  290. — Diagram  of  Section  of  Capsule  in  Normal  and  in  Congenitally  Dislocated  Hip. 

distorted   capsule   into  the   socket.      The    following  method   will  be 
found  serviceable : 

Complete  anaesthesia  is  necessary.     The  child's  ankle  is  grasped 
firmly  and  a  strong  pull  exerted,  counter-pull  being  furnished  by  an 


FIG.  292. 


FIG.  291. 

FIGS.  291.  and  292. — Diagram  Showing  Difficulties  in  Reduction.  i,  In  the  capsule  covering 
the  acetabulum;  2,  in  the  shortened  capsule  between  the  acetabular  rim  and  the  lesser 
trochanter. 

assistant  who  presses  upon  the  perineum.  The  limb  should  be  rotated 
forcibly  to  both  the  outer  and  inner  side,  and  then  forcibly  abducted 
both  with  the  knee  flexed  and  straight. 


332 


ORTHOPEDIC  SURGERY 


It  is  essential  that  the  adductor  group  of  muscles  should  be  over- 
stretched. After  the  limb  has  been  brought  to  nearly  a  right  angle  with 
the  axis  of  the  trunk,  the  knee  being  straight,  it  should  be  again 
brought  in  a  line  of  the  axis  of  the  trunk  and  then  forced  upward 
with  the  knee  straight,  until  the  thorax  is  almost  touched  by  the  front 


FIG.  293. — Congenital   Dislocation.      Reduction  by  incision.      Osteotomy  of  shaft  to  correct 

twist  of  neck. 


of  the  thigh,  thus  stretching  the  hamstring  muscles.  The  child  should 
then  be  turned  upon  its  face  and  forcible  hyperextension  used,  both 
with  the  leg  abducted  and  straight.  The  child  is  then  placed  upon 
its  back  and  reduction  attempted,  the  surgeon  holding  the  patient's 
limb  just  below  the  knee,  which  is  flexed  and  abducted  strongly  with 
one  hand,  the  other  hand  being  placed  upon  the  pelvis,  the  palm 
pressing  on  the  crest  of  the  ilium  and  the  thumb  passing  behind  and 
beneath  the  trochanter. 

The  child  is  then  placed  upon  its  back  and  an  attempt  at  reduction 


CONGENITAL  DISLOCATIONS 


333 


made.     If  the  tissues  have  been  sufficiently  stretched  by  the  above- 
mentioned  manoeuvres,  the  reduction  can  be  made  with  the  exercise 


FIG.  294.  FIG   295. 

FIGS.  294 and295.— Diagram  Showing  Pelvi-trochanteric  and  Pelvic  Muscles  in  Congenital 

Dislocation  of  Hip. 

of  a  little  skill.  The  surgeon  holds  the  patient's  limb  just  below 
the  knee  with  the  hand,  abducts  the  limb  strongly,  flexing  it  at  the 
knee.  The  other  hand  is  placed  upon  the  pelvis,  the  palm  of  the  hand 


FIG.  296. — Manipulative    Reduction   in   Congenital   Dislocation   of  the   Hip.      Traction   and 

reduction. 

resting  on  the  anterior  spine,  and  the  thumb  being  placed  under  the 
trochanter,  while  an  assistant  steadies  the  pelvis  by  pressing  upon 
the  opposite  side.  The  patient's  knee  is  moved  outward  and  toward 


334 


ORTHOPEDIC  SURGERY 


the  plane  of  the  operating  table,  while  the  trochanter  is  pressed  upward 
and  slightly  forward.  In  successful  cases  the  head  will  be  felt  to  slip 
into  the  acetabulnm  with  a  sudden  movement  characteristic  of  the 
reduction  of  a  dislocation. 

It  is  often  necessary  to  give  slight  rotary  motion  to  the  limb  and 


FIG.  297. — Manipulative   Reduction.      Forced  abduction   stretching  the  adductors  with  blows   upon 

the   adductor   attachment. 

slight  manipulation  is  often  necessary.  The  surgeon  should  by 
manipulation  determine  the  size  and  depth  of  the  acetabulum,  and 
the  firmness  with  which  it  is  held  in  the  acetabulum  is  also  to  be 
noted. 

In  the  more  resistant  cases  a  padded,  wedge-shaped  block  placed 


FIG.  .298. — Manipulative   Reduction.      Forced   flexion  with   leg  straight  at  knee. 

behind  the  trochanter  will  be  of  assistance,  serving  to  push  the  tro- 
chanter and  head  of  the  femur  forward,  while  the  patient's  knee  is 
pressed  downward.  When  the  head  of  the  femur  is  well  in  the 
acetabulum  it  can  be  felt  on  careful  palpation,  lying  under  the  point 
of  intersection  of  a  line  following  the  femoral  artery,  with  a  line 
crossing  the  pelvis  at  a  level  with  the  top  of  the  symphysis  pubis.  A 


CONGENITAL  DISLOCATIONS 


335 


tightening  of  the  hamstrings  will  usually  be  observed  after  reduction 
of  the  hip.     After  the  reduction  has  been  made,  the  limb  should  be 


FIG.  299. — Manipulative   Reduction.      Hyperextension. 

carefully  brought  into  a  straight  position,  i.e.,  parallel  with  the  long 
axis  of  the  trunk.     If  dislocation  occurs  during  this  manipulation 


FIG.  300. — Manipulative    Reduction.      Head   of   femur   pressed   into   acctabulum   by   manipulation 
after   all   contracted   tissues   are   relaxed   by   overstretching. 


the  tissues  must  be  stretched  still  further  and  the  head  again  placed 
in  the  acetabulum. 


336  ORTHOPEDIC  SURGERY 

REDUCTION  WITH  THE  Am  OF  MECHANICAL  FORCE. 

In  the  younger  cases  little  difficulty  will  be  encountered  in  stretch- 
ing the  shortened  muscles  by  the  use  of  manipulation  as  described,  but 
in  older  cases  much  force  is  necessary,  which  involves  danger  of 
fracture  of  the  femur  or  pelvis,  both  of  which  accidents  have  occurred 
in  manipulative  reduction.  A  difficulty  encountered  where  manual 
force  is  employed  is  in  holding  the  pelvis.  This  is  essential  to  the 
accurate  employment  of  force,  and  the  accurate  employment  of  force 
is  of  the  greatest  importance  if  much  force  is  to  be  used. 

It  is  for  this  reason  that  mechanical  aids  have  been  advised  in 
the  reduction  of  congenitally  dislocated  hips.1 

The  appliance  at  present  employed  by  the  writers  will  be  found  to 
be  of  service. 

Traction  is  furnished  by  means  of  a  movable  traction  rod  playing 
upon  a  socket  placed  near  the  hip-joint.  Traction  is  furnished  by  a 
screw  force  pulling  upon  a  leather  anklet  bound  on  the  patient's 
ankle.  A  counter  force  is  furnished  by  uprights  pressing  on  the 
perineum  to  prevent  the  riding  upward  of  the  trochanter.  As  the 
limb  is  abducted  steel  pegs  are  placed  upright  above  the  trochanter 
and  close  to  the  pelvis,  inserted  in  a  steel  plate  on  which  the  patient 
lies.  On  these  and  on  the  perineal  uprights  steel  plates  are  placed,  pre- 
venting movement  of  the  ilium  and  symphysis  pubis.  The  pelvis  is 
firmly  held.  A  steel  lever  rod,  with  its  end  inserted  in  a  hole  in  the 
steel  plate  held  by  the  surgeon,  can  be  made  to  press  on  the  trochanter 
and  femoral  neck  and  serve  to  exert  force  downward  and  inward  on 
the  head  and  neck  or  to  lift  it  over  the  acetabulum  ridge.  While 
the  limb  is  stronglv  pulled  and  abducted  by  this  means  the 
head  can  often  be  forced  safely  through  the  capsular  constriction 
in  resistant  cases  where  manual  manipulation  fails.  This  apparatus 
has  been  elaborated  by  Fitzsimmons  and  Sanfcrd  and  other  forms 
of  traction  apparatus  are  in  use.  The  use  of  some  apparatus  of 
this  sort  makes  it  possible  to  reduce  a  larger  proportion  of  the 
more  difficult  cases  than  can  be  reduced  by  the  purely  manual 
methods. 

Accidents. — The  method  of  reduction  of  congenital  femoral  dis- 
location by  manipulation  is  not  without  danger  and  requires  the  exer- 

1  One  of  the  most  efficient  of  apparatus  for  the  purpose  is  an  appliance  devised 
by  Mr.  Ralph  W.  Bartlett,  of  Boston.  For  a  full  description  of  this  excellent  ap- 
paratus the  reader  is  referred  to  the  former  edition  of  the  authors'  Treatise  on 
Orthopedic  Surgery,  and  to  the  Journal  of  Med.  Research,  December,  1903. 


CONGENITAL  DISLOCATIONS 


337 


cise  of  considerable  judgment.  Fracture  of  the  femoral  head,  frac- 
ture of  the  pelvis,  death  from  shock,  rupture  of  the  femoral  artery, 
and  temporary  and  permanent  paralyses  have  all  followed  the  in- 


FIG.  301. — Line    of     FIG.  y.-z. — Second          FIG.  303. — Third 
Incision     for     Op-  Step.  Step, 

erative   Reduction. 


FIG.   304. — Fourth   Step. 


judicious  use  of  force  in  correcting  this  deformity.     These  accidents 
can  be  avoided  if  the  method  is  limited  to  the  less  severe  cases. 


FIG.  305. — Result  of  Reduction  in  Congenital  Dislocation  of  the  Hip. 

From  the  experience  at  the  Boston  Children's  Hospital  it  would 
appear  that  the  danger  of  injury  in  forcible  reduction  is  diminished 
by  the  employment  of  the  mechanical  appliance  mentioned.  Great 


338 


ORTHOPEDIC  SURGERY 


care  and  judgment,  however,  are  necessary  in  the  use  of  this  as  of 
all  powerful  aids. 

AFTER-TREATMENT. — After  the  hip  has  been  placed  in  the  acetabu- 
lum,  it  is  necessary  that  it  should  be  held  in  the  socket  until  the 
capsular  tissues  are  sufficiently  strong  to  prevent  a  relapse. 

The  child,  while  still  under  the  amesthetic,  is  placed  upon  a  pelvic 


FIG.  306. — Skiagram  Taken  Seven  Years  after   Reduction  of  a  Dislocated   Right  Hip,  at  the  Age 

of  Twelve  Years. 


support  and  a  firm  plaster  bandage  applied  to  the  thigh  and  pelvis, 
protected  by  stockinet,  felt,  and  cotton. 

Surgeons  vary  in  their  recommendations  as  to  the  best  position  in 
after-treatment.  This  must  necessarily  vary  in  different  cases  accord- 
ing to  varying  conditions.  The  writers  ordinarily  prefer  to  place 
the  limb  with  the  patella  pointing  forward  and  the  leg  (the  knee 
being  bent)  pointing  backward,  the  thigh  being  strongly  abducted  and 
flexed.  For  the  first  two  weeks  the  plaster  bandage  should  pass 
around  the  hip  not  operated  upon  to  give  greater  fixation.  This  can 
later  be  removed  and  more  motion  of  the  affected  limb  permitted. 
The  child  can  then  walk  about  with  crutches. 

The  length  of  time  during  which  it  is  necessary  that  the  plaster 
bandage  should  be  worn  varies,  with  each  case,  from  two  to  six 
months,  with  a  change  of  plasters  as  may  be  required  for  cleanliness 
and  examination  of  the  hip.  After  the  time  has  passed  when  plaster 
fixation  is  no  longer  necessary,  daily  exercise  should  be  given,  directed 
to  increasing  the  motion  at  the  hip-joint.  It  is  necessary  to  stimulate 


CONGENITAL  DISLOCATIONS 


339 


the  muscles  which  are  not  being  used,  and  to  stretch  by  gradual  exer- 
cise the  muscles  which  may  remain  contracted.  The  patient  should 
be  given  both  passive  and  active  exercises.  In  the  passive  exercises  the 
manipulator  should  place  one  hand  upon  the  pelvis  with  slight  pressure 
above  the  trochanter,  and  with  the  other  move  the  femur  in  the 


FIG.  307. — Six   and   One-half   Years   Old.      Congenital    dislocation   of   left   hip.       One  year   after 
reduction  by  operative  mechanical   stretching  and  manipulation. 

direction  of  flexion  and  adduction,  the  patient  being  recumbent. 
Movement  should  also  be  made  to  straighten  the  limb  at  the  knee 
and  turn  the  foot  inward,  bringing  the  limb  gradually  in  the  direction 
parallel  with  the  other.  Similar  active  exercises  can  be  undertaken 
and  conducted  with  care  daily. 

Relapse  may  follow  where  the  capsular  tissue  fails  to  hold  with 
sufficient  firmness  in  the  acetabulum  the  femoral  head  after  reduction. 


340 


ORTHOPEDIC  SURGERY 


This  takes  place  when  a  cotyloicl  ligament  is  not  developed,  and  when 
the  muscles  are  not  sufficiently  strong  to  keep  the  femoral  head  in 
place,  or  when  tissues,  contracted  in  the  flexed  and  strongly  abducted 


FIG.  308.— Showing    Strength    of    Reduced    Hip    by    the    Trendelenburg    Test.        Motion    and    gait 

of  reduced  hip  normal. 

position  of  after-treatment,  prevent  the  placing  of  the  limb  in  the 
normal  position  without  causing  displacement. 

Care  in  after-treatment  may  prevent  relapses  in  many  instances 
of  this  class.  Careful  examination  of  the  cases  during  after-treatment 
by  manipulation  and  with  the  skiagraph,  the  use  of  gymnastics,  and 
massage  will  be  of  advantage  in  restoring  the  muscles  to  their  normal 
condition. 

Relapses  result  also  from  abnormality  in  the  shape  of  the  femoral 
head  and  in  the  shape  of  the  acetabulum.  It  is  impossible  by  manipu- 


CONGENITAL  DISLOCATIONS  341 

lative  reduction  to  place  securely  a  distorted  femoral  head  into  an 
equally  distorted  and  smaller  acetabulum.  Permanent  reduction  is 
also  made  difficult  by  the  twist  of  the  femur,  which  gives  an  abnormal 
direction  to  the  femoral  neck  and  consequent  abnormal  muscular  rela- 


FIG.  309. — Untreated    Case   of    Double    Congenital    Dislocation.       Unable   to    walk    without 

crutches. 

tion.  The  importance  of  the  femoral  twrist  in  causing  relapse  after 
congenital  dislocation  has  been  exaggerated.  It  has  been  found  by  the 
investigation  of  Mikulicz  and  also  by  Soutter  that  a  femoral  twist 
may  exist  to  a  considerable  extent  without  causing  noticeable  dis- 
ability. When  a  femoral  twist  of  ninety  degrees  is  present,  it  is 
impossible  for  the  patient  to  walk  normally  with  the  femoral  head 
in  the  socket.  Under  these  circumstances  an  osteotomy  of  the  femur 
is  necessarv. 


342  ORTHOPEDIC  SURGERY 

OSTEOTOMY. — When  such  an  osteotomy  is  necessary  it  can  be  per- 
formed by  the  use  of  an  osteotome,  dividing  the  femur  beneath  the 
lesser  trochanter  by  a  linear  osteotomy. 

PROGNOSIS  AFTER  TREATMENT. — The  results  obtained  in  the  treat- 
ment of  congenital  dislocation  of  the  hip  show  a  gratifying  increase  in 


FIG.  310. — Double   Congenital    Dislocation   of   Hip.      Child   aged   four.      Untreated. 

the  percentage  of  permanent  cures  as  the  knowledge  of  the  pathological 
conditions  of  the  deformity  has  been  more  thoroughly  understood  and 
as  technical  skill  has  increased.  Permanent  cures  (i.e.,  successful 
anatomical  replacements,  with  re-establishment  of  motion)  can  be 
expected  in  80  to  90  per  cent  of  cases  suitable  for  operation  (i.e.,  be- 
tween 2  and  10  years  of  age).  In  some  of  the  younger  children  and  in 
the  double  cases  a  second  reduction  is  sometimes  needed,  when  the  head 
is  not  held  firmly  in  the  socket  after  the  first  operation. 

REDUCTION  BY  OPEN  INCISION. 

In  the  more  resistant  older  cases,  where  manipulative  reduction 
has  failed,  reduction  by  incision  can  be  employed  with  success.     This 


CONGENITAL  DISLOCATIONS  343 

procedure  is  one  which  requires  the  exercise  of  skill.  Traction  is  first 
applied  to  pull  the  head  as  near  to  its  proper  place  as  possible.  It 
is  then  cut  down  upon,  with  as  little  injury  to  the  muscles  as  possible, 
the  capsule  is  opened,  and  capsular  constriction  divided  by  means 
of  a  herniotome  and  stretched.  All  ligamentous  and  fibrous  bands 


FIG.  311. — Apparatus  for  Reduction  of  Congenital  Dislocation  of  the  Hip. 

which  are  obstacles  to  reduction  are  cut,  the  head  reduced,  and  the 
capsule  stretched  firmly  around  the  neck.  The  operation  should  be 
done  under  the  strictest  asepsis  and  the  limb  secured  by  a  plaster 
bandage  in  an  abducted  position. 

After  the  reduction  the  redundant  capsule  can  be  closed,  with  a 
wick  for  drainage,  or  packed,  according  to  the  judgment  of  the  sur- 
geon. When  absolute  confidence  can  be  placed  in  thorough  asepsis, 
closing  the  wound  in  this  way  at  the  time  of  operation  saves  for  the 
patient  a  long  period  of  wound-healing.  The  limb  should  be  fixed 
by  means  of  a  plaster-of-Paris  spica  reaching  from  the  thorax  down 
to  the  foot,  holding  the  limb  in  a  strongly  abducted  position.  The 
position  of  the  limb  should  be  that  of  strong  abduction. 


344 


ORTHOPEDIC  SURGERY 


SUMMARY. 

Surgeons  will  vary  somewhat  in  their  choice  of  methods  of  opera- 
tion, according  to  their  experience  and  success  with  the  methods  of 


FIG.  312. — Same    Patient,    Age    Twenty-eight.      Untreated    case.      Patient   able    to    walk   actively 

with  little  limp.     Cf.  Fig.  310 

reduction  by  forcible  manipulation  or  by  open  incision,  but  these  facts 
may  be  said  to  be  generally  accepted : 


CONGENITAL  DISLOCATIONS  345 

As  a  rule  no  attempt  at  reduction  is  advisable  under  two  years  of 
age,  as  the  tissues  are  not  sufficiently  developed  to  prevent  relapse. 

In  the  early  cases,  from  two  to  five  years  of  age,  reduction  is 
easily  accomplished  by  forcible  manipulation. 

In  older  cases,  from  five  to  ten,  except  in  children  with  weak 
muscles,  although  reduction  by  forcible  manipulation  is  often  not 
difficult,  reduction  is  much  easier  after  mechanical  stretching,  and  in 
some  cases  reduction  is  impossible  without  such  aid. 

In  resistant  cases,  where  there  is  reason  to  believe  alteration  of 
the  shape  of  the  head  and  acetabulum  or  a  firm  and  narrow  hour- 
glass contraction  of  the  capsule  exist,  an  attempt  should  be  made  to 
reduce  the  dislocation  by  means  of  the  apparatus  mentioned,  and  if 
this  fails  one  should  undertake  reduction  by  open  incision  after  a  thor- 
ough stretching  of  the  muscular  tissues. 

In  cases  of  doubt  as  to  which  method  to  employ,  the  surgeon  can 
regard  it  as  a  safe  rule  to  follow  to  attempt  reduction  first  by  forcible 
manipulation,  employing  open  incision  if  relapse  follows. 

The  length  of  time  needed  in  after-treatment  must  be  determined 
by  the  condition  found  after  reduction,  and  must  be  left  to  individual 
judgment  in  each  case. 

Double  cases  are  to  be  regarded  as  more  than  twice  as  difficult  as 
single.  Attempts  at  reduction  by  forcible  manipulation  should  be  made 
on  both  hips  at  the  same  time,  but  if  open  incision  is  employed,  as  a 
rule  two  separate  operations  are  necessary. 

Congenital  dislocation  of  the  knee  is  seen  with  greater  frequency 
than  that  of  some  of  the  other  joints.1  It  occurs  most  often  in  the 
form  of  hyperextension  of  the  leg  on  the  thigh,  which  has  been 
considered  by  some  writers  a  displacement  rather  than  a  true  disloca- 
tion forward.  In  some  cases  the  lower  epiphysis  of  the  femur  is  bent 
forward  on  the  shaft.2  It  is  in  any  event  a  congenital  affection  of 
importance  when  it  occurs.  It  is  frequently  double,  and  the  displace- 
ment may  be  directly  forward  or  forward  and  to  one  side.  The  leg 
"forms  a  right  angle  with  the  thigh,  the  apex  of  the  angle  being 
backward,  and  the  condyles  of  the  femur  can  be  felt  in  the  popliteal 
space ;  the  patella  is  often  small  and  occasionally  absent,  and  lateral 
mobility  may  be  present.  The  affection  is  also  known  as  genu  recurva- 
tum.  Modifications  in  the  shape  of  the  bone,  ligaments,  and  carti- 
lages in  the  knee-joint,  even  to  the  point  of  ankylosis,  have  been 

iDrehman:  Zeitsch.  f.  orth.  Chir..  vii.,  22.  (98  cases). 
2Delanglade:  Rev.  d'Orthopedie,  May,  1903. 


346  ORTHOPEDIC  SURGERY 

recorded  in  some  of  these  cases.  The  deformity  may  be  associated 
with  malformation  of  other  parts,  and  the  cause  can  be  given  no  more 
clearly  than  that  of  other  congenital  deformities. 

Forward  displacement  of  the  leg  at  the  knee  is  to  be  treated  by 
manipulation  in  the  direction  of  correction  and  the  application  of  a 
repeated  plaster  bandage  to  the  knee  to  force  the  limb  into  a  corrected 

position. 

PATELLA. 

Dislocation  of  the  patella  is  among  the  more  common  of  the 
congenital  dislocations ;  many  cases  reported  as  congenital  have,  how- 
ever, been  doubted. 

The  type  most  frequently  seen  is  outward  dislocation  existing  with 
some  degree  of  knock-knee.  It  may  be  displaced  inward  or  upward, 
in  the  latter  case  being  associated  with  lengthening  of  the  patella 


\       / 

X  f 

NTT 


FIG.  313. — Congenital  Dislocation  of  the  Knee.      (Genu  recurvatum  with   club-foot.) 

tendon.  There  may  be,  in  connection  with  the  dislocation  outward, 
absence  or  flattening  of  the  outer  condyle  of  the  femur. 

The  disability  may  be  slight  or  there  may  be  marked  impairment 
of  the  extension  power  of  the  leg  on  the  thigh.  Treatment  by  opera- 
tion would  be  similar  to  that  described  in  speaking  of  slipping  patella. 

CONGENITAL  ABSENCE  OF  THE  PATELLA.* — The  patella  may  be 
absent  or  tardy  in  its  development.  If  it  is  absent  the  knee  appears 
broad  and  flat  and  there  may  be  marked  impairment  of  the  function 
of  the  knee.  In  other  cases  the  knee  is  useful.  It  may  coexist  with 
other  malformations  of  the  knee,  especially  genu  recurvatum.  It  is 
often  bilateral  and  is  frequently  associated  with  club-foot  and  similar 
deformities. 

The  treatment  consists  in  the  use  of  apparatus  to  support  the  de- 
fective joint,  and  massage  and  muscle  training  to  the  extensor  muscles. 
1A.  Thorndike:  Orth.  Trans.,  vol.  xi. 


CONGENITAL  DISLOCATIONS  347 

SHOULDER. 

True  congenital  dislocation  of  this  joint  is  rare,  and  many  cases 
reported  as  congenital  have  proved  on  investigation  to  be  dislocations 
due  to  paralysis  or  due  to  injury  to  the  shoulder  at  birth,  resulting 
most  often  in  a  separation  of  the  epiphysis.  The  dislocation  found 
is  the  subspinous,  but  other  varieties  have  been  recorded,  such  as 
the  subcoracoid  and  subacromial.  Double  dislocation  of  the  shoulder 
has  been  described  and  in  some  cases  has  been  associated  with  other 
malformations.  The  glenoid  cavity  is  likely  to  be  malformed,  as  in  a 
case  reported  by  Smith,  where  there  was  hardly  a  trace  of  the  normal 
glenoid  cavity.  In  other  cases  it  is  approximately  normal.  The  lim- 
itation of  function  is  similar  to  that  in  traumatic  dislocations.  Cases 
of  dislocation  of  the  shoulder-joint  in  young  infants  have  been  re- 
duced with  or  without  incision,  with  improvement  in  the  usefulness 
of  the  arm;  cases  of  true  congenital  dislocation,  however,  improved 
by  operation  are  few.  Cases  were  operated  on  by  Phelps  by  doing 
what  was  practically  an  arthrodesis  through  a  posterior  incision,  and 
the  redundant  capsule  was  removed.  The  chances  of  successful  re- 
placement would  be  greater  in  cases  with  a  normal  glenoid  cavity 
and  in  cases  undertaken  early  in  life.  In  later  childhood  the  prospect 
is  less  good. 

In  addition  to  the  operative  reduction,  reduction  by  manipulation 
is  to  be  considered,  following  the  lines  indicated  in  the  operation  for 
congenital  dislocation  of  the  hip.  After  replacement  the  arm  should 
be  held  by  a  plaster  bandage  for  some  months  in  a  position  of  abduc- 
tion and  outward  rotation. 

ELBOW. 

Congenital  dislocations  of  the  elbow  are  very  rare  and  of  com- 
paratively little  practical  importance.  The  reported  cases  do  not  con- 
form to  any  one  type,  following  a  wide  range  of  variation. 

In  connection  with  congenital  dislocation  of  the  elbow  may  be 
mentioned  a  deviation  from  the  normal  line  of  the  arm  occasionally 
seen.  If  the  arm  of  the  adult  hangs  at  the  side  with  the  palm  of 
the  hand  directed  forward,  the  line  of  the  forearm  should  form  with 
the  line  of  the  arm  an  angle  of  about  169  degrees  with  a  variation  of 
10  degrees  in  either  direction.  The  outward  deviation  of  the  forearm 
is  a  few  degrees  greater  in  women  than  in  men.  Ciibitns  valgus  is  the 
name  applied  to  the  condition  in  which  the  forearm  is  displaced  too 


348  ORTHOPEDIC  SURGERY 

far  to  the  radial  side;  cubitus  varus,  the  condition  in  which  it  is  dis- 
placed to  the  ulnar  side.  Trauma  is  the  most  frequent  cause  of  the 
marked  varieties.  They  are  also  associated  with  rickets  and  the  ele- 
ment of  inheritance  apparently  plays  a  part.  In  case  either  deformity 
should  be  severe  enough  to  require  operative  treatment,  an  osteotomy 
may  be  done  similar  to  the  Aiacewen  operation  for  knock-knee. 

WRIST. 

Pure  congenital  dislocation  of  the  wrist  is  extremely  rare.  The 
ordinary  form  in  which  it  is  seen  is  in  connection  with  club-hand. 

SPONTANEOUS  SUULUXATION  OF  THE  WRIST. — A  displacement 
of  the  wrist  has  been  described  by  Madelung,  in  which  the  hand  is 
displaced  to  the  palmar  side  of  the  forearm  and  probably  to  either 
the  radial  or  the  ulnar  side  laterally,  generally  to  the  former.  In 
such  cases  the  lower  border  of  the  radius  and  that  of  the  ulna  are 
prominent  at  the  dorsum  of  the  wrist,  and  the  bones  are  somewhat 
separated  from  each  other.  The  wrist  is  much  increased  in  thick- 
ness and  the  function  of  the  hand  is  impaired.  Active  and  passive 
dorsal  flexion  are  affected  and  some  pain  may  be  present,  especially 
in  dorsal  flexion.  The  hand  can  be  replaced  only  in  the  lighter 
grades  of  the  affection.  There  is  excessive  mobility  of  the  intercarpal 
joint  and  there  may  be  slight  forward  bending  of  the  lower  extremity 
of  the  radius. 

Aside  from  the  pain  which  may  be  present,  the  symptoms  are 
weakness  and  sensations  of  discomfort  about  the  wrist.  The  causes 
of  the  affection  are  given  as  relaxation  of  the  ligaments,  stretching 
of  the  muscles  by  hard  work,  irregularity  of  growth  at  the  lower 
end  of  the  radius,  and  possibly  a  malposition  lasting  over  from  rickets. 
The  treatment  is  at  first  hyperextension  of  the  joint  by  means  of 
bandages  and  splints,  the  use  of  massage  and  similar  measures,  and 
osteotomy  in  cases  with  bony  deformity  sufficient  to  require  it. 


CHAPTER  XVIII. 

TALIPES,  CONGENITAL  AND  ACQUIRED 
(CLUB-FOOT). 

THE  name  talipes  signifies  a  deformity  of  the  foot,  and,  although 
it  was  originally  used  to  indicate  a  form  of  talipes  now  known  as 
equino-varus  or  club-foot,  the  present  use  of  this  word  is  as  a  prefix 
to  the  descriptive  adjective  designating  the  variety  of  the  deformity 
which  exists. 

TALIPES   EQUINO-VARUS    (CLUB-FOOT). 

The  term  club-foot  is  popularly  applied  to  a  deformity  char- 
acterized by  an  inversion,  torsion,  and  depression  of  the  front  part 
of  the  foot  with  an  elevation  of  the  heel. 

In  walking  on  a  foot  thus  deformed,  the  weight  of  the  body  is 
borne,  not  by  the  sole  of  the  foot,  but  by  the  outer  side,  and  in  ex- 
treme cases  by  a  portion  of  the  dorsum  of  the  foot  also. 

The  deformity  is  either  congenital  or  acquired. 

Frequency. — Club-foot  is  by  no  means  an  uncommon  distortion. 
In  6,969  orthopedic  patients  applying  at  the  out-patient  department 
of  the  Children's  Hospital,  Boston,  there  were  488  cases  of  club-foot. 
Congenital  club-foot  is  by  far  the  most  frequent  of  the  congenital 
deformities  of  the  foot. 

Pathological  Anatomy — The  deformity  is  a  displacement  inward 
of  the  anterior  part  of  the  foot.  The  scaphoid  bone  will  be  found 
articulating  with  the  side  of  the  head  of  the  astragalus  rather  than 
with  the  anterior  surface.  The  articulation  is  also  more  toward  the 
under  side  of  the  astragalus,  the  head  of  which  is  thus  partially 
uncovered. 

The  cuneiform  bones,  being  intimately  connected  with  the 
scaphoid,  follow  the  displacement  of  the  latter,  and  the  same  is  true 
of  the  metatarsal  bones  and  the  phalanges,  so  that  the  long  axis  of  the 
front  of  the  foot  forms  a  right  angle,  or  even  an  acute  angle,  with 
the  axis  of  the  leg.  The  cuboid  is  necessarily  displaced  to  the  inner 
side  and  does  not  articulate  with  the  front  of  the  os  calcis,  the  facet 
of  which  also  inclines  obliquely  to  the  inner  side. 

349 


350 


ORTHOPEDIC  SURGERY 


In  fully  developed  cases,  and  in  older  children  or  adults,  there 
is  a  more  marked  and  important  alteration  in  the  shape  of  the  bones. 

The  os  calcis,  by  the  elevation  of  the  tuberosity,  is  drawn  from 
a  horizontal  into  a  position  approaching  the  vertical.  It  is  also  more 
or  less  rotated  on  its  vertical  axis,  so  that  its  anterior  extremity  is 
directed  outward  and  the  posterior  extremity  inward,  and  thus  the 
anterior  articulating  facet  is  oblique  to  the  axis  of  the  Done.  The 


FIG.  314. — Dissection   of  Club-foot. 


cuboid  bone  maintains  its  connection  with  the  os  calcis,  but  follows  the 
inward  direction  of  the  anterior  extremity  of  the  foot. 

The  different  tendons  assume  an  abnormal  direction  and  in  gen- 
eral are  carried  farther  to  the  inside  than  is  normal ;  this  is  especially 
true  of  the  tibialis  anticus,  the  common  extensor  of  the  toes,  and 
the  long  extensor  of  the  great  toe.  Synovial  bursse  may  form  on 
the  outer  edge  and  back  of  the  foot,  which  may  become  inflamed  and 
suppurate;  corns  and  callosities  are  also  formed  on  the  skin,  from 
the  pressure  of  walking.  Xo  change  has  been  found  in  the  nerves 
or  the  spinal  cord  in  cases  of  club-foot. 

In  extreme  cases  there  may  be  slight  alteration  in  the  shape  of  the 
femur  and  a  laxity  at  the  knee-joint ;  the  tibia  has  also  been  found 
altered.  The  muscles  are  never  found  paralyzed  in  congenital  club- 
foot,  but  the  contracted  muscles  seem  more  developed  than  the  length- 


TALIPES 


COLLEGE  OF  O 


YGF 


35i 


ened  muscles.  The  muscles  of  the  leg  atrophy  from  disuse,  and  the 
leg  is  much  smaller  and  the  foot  shorter  than  normal. 

Etiology. — In  regard  to  the  etiology  of  congenital  club-foot,  vari- 
ous theories  have  been  advanced  in  explanation  of  the  deformity. 

A  popular  idea  is  that  the  distortion  is  due  to  maternal  impres- 
sions, but  no  conclusive  evidence  in  regard  to  this  has  been  obtained. 

Heredity,  on  the  part  of  both  the  father  and  mother,  has  been 


FIG.  315.  FIG.  316.  FIG.  317. 

FIG.  315. — Diagram    Indicating    Mid-tarsal    Articulation    in    Club-foot    and    the    alteration    in   the 

positions   of   the   scaphoid   and   cuboid    in  their   relation   to   the   astragalus  and  os   calcis — with 

alteration  in  the  shape  of  front  of  os  calcis. 
biG.  316. — Diagram  of  a  Normal   Foot. 
FIG.  317-: — Diagram   of  a   Club-foot   Partially   Corrected,   Leaving  the   Projection   of   Front  of   Os 

Calcis    Unchanged,    and    the    Consequent    Imperfect    Reduction    of    the    Cuboid.       A    relapse 

necessarily  follows. 

established  without  doubt  in  a  certain  number  of  cases,  but  in  a  very 
large  majority  no  trace  of  similar  deformity  in  ancestors  can  be 
found.  It  seems  probable  that  the  two  most  common  causes  of  the 
deformity  are  abnormal  intrauterine  pressure  or  a  perversion  of  the 
normal  intrauterine  development. 

Symptoms. — Club-foot  gives  rise  to  great  inconvenience  in  walk- 
ing. In  uncorrected  cases,  however,  the  amount  of  skill  and  agility 
patients  acquire  in  locomotion  is  surprising,  even  though  the  deformity 
remains  unchanged.  Bursse  and  callosities  form  over  the  unprotected 
portions  of  the  foot,  and  may  inflame  and  cause  much  discomfort, 
limiting  the  amount  of  the  patient's  activity. 

Diagnosis. — There  is  no  difficulty  in  recognizing  the  deformity  of 
club-foot.  The  history  of  the  case  establishes  a  diagnosis  between 
the  congenital  and  non-congenital  forms  of  club-foot.  The  paralytic 


352 


ORTHOPEDIC  SURGERY 


form  can  also  be  recognized  by  the  evidence  of  paralysis  of  the  muscles 
on  the  anterior  and  external  surface  of  the  leg. 

Prognosis. — In  regard  to  the  prognosis  of  the  deformity,  it  may 
be  said  that  the  distortion  does  not  correct  itself,  and,  if  left  uncor- 
rected,  remains  the  most  obstinate  of  malformations.  The  deformity 
is  one  which  is  essentially  curable  through  surgical  intervention. 

In  infantile  cases  the  time  required  for  correction  is  relatively 
short,  but  retentive  appliances  are  needed  for  a  longer  time.  It  may 


FIG.  318. — Double  Congenital   Club-foot. 

be  said  in  general  that  the  older  the  cases  and  the  larger  the  foot  the 
more  difficult  the  correction,  but  the  less  the  danger  of  relapse  after 
correction. 

In  regard  to  the  permanence  of  the  cure  and  the  danger  of  relapse, 
it  may  be  said  that  if  perfect  overcorrection  is  attained  relapse  is  excep- 
tional, if  moderate  care  is  used  in  the  employment  for  a  sufficient 
time  of  retentive  appliance. 

But  it  must  be  borne  in  mind,  especially  in  the  case  of  young  chil- 
dren, not  only  that  the  overcorrection  must  be  complete,  but  that  effi- 
cient appliances  for  keeping  the  proper  position  of  the  foot  in  walking 


TALIPES  353 

(retentive  or  walking  appliances  to  be  described)  must  be  worn  until 
the  gait  and  attitude  are  perfect.  In  club-foot  half-cures  are  prac- 
tically no  cures.  Relapsed  cases  are  invariably  resistant  and  difficult 
to  correct. 

Treatment. — The  object  of  treatment  is  the  overcorrection  of  the 
distortion  and  the  retention  of  the  foot  in  an  overcorrected  position 


FIG.  319. — Congenital  Club-foot.  Cured  club.  Twenty-four  years  after  correction  in  infancy 
by  tenotomy,  manual  force  and  retention,  walking  appliance  worn  for  two  years.  Patient 
able  to  walk  without  limp  or  discomfort  twenty  miles  a  day. 

until  any  return  of  the  deformity  is  impossible,  the  tendency  to  relapse 
being  very  strong. 

The  treatment  should  be  purely  mechanical,  or  both  operative  and 
mechanical. 

The  treatment  of  club-foot,  therefore,  requires: 

i.  A  rectification  of  the  misplaced  bones  and  a  lengthening  of 
shortened  and  contracted  tissues. 


354  ORTHOPEDIC  SURGERY 

2.  A  retention  in  an  overcorrected  position  until  the  abnormal  facet 
of  the  astragalus  and  the  other  tissues  become,  under  the  pressure  of 
new  position,  normal. 

At  the  present  time  few  procedures  in  surgery  are  as  precise  in 
their  indications  and  as  certain  in  their  results  as  the  methods  for 
the  correcting  of  club-foot. 

The  correction  of  club-foot  should  be  divided  into  two  steps, 
whether  the  treatment  is  mechanical  or  operative. 

ist.  Correction  of  the  varus  deformity. 

2(1.   Correction  of  the  equinus  deformity. 

In  other  words,  the  front  of  the  foot  should  be  twisted  out  and 
afterward  be  raised.  This  will  be  found  of  practical  importance,  as 
the  foot  is  more  easily  twisted  before  than  after  the  equinus  deformity 
is  overcome. 

Operative  treatment  in  some  form  is  the  method  to  be  selected  in 
cases  of  congenital  club-foot,  except  in  young  infants  and  in  older 
children  when  some  centra-indication  to  operation  exists. 

The  mechanical  procedures  for  correcting  club-foot  are  as  follows : 

Manual  manipulation. 

Plaster-of-Paris  bandages. 

Apparatus. 

The  operative  procedures  which  are  to  be  considered  in  treating 
club-foot  are : 

Tenotomy. 

Division  of  the  ligaments. 

Open  incision. 

Forcible  correction  and  osteotomy. 

MECHANICAL  CORRECTION. 

Manual. — The  simplest  method  of  correction  is  by  the  use  of  the 
hands,  and  in  the  case  of  a  new-born  infant  with  club-feet  the  mother 
may  be  directed  to  manipulate  the  foot,  and  having  rectified  the  de- 
formity by  gentle  force  several  times  daily,  to  hold  it  as  straight  as 
possible  for  a  minute  or  two  each  time.  This  process  continued  daily 
over  a  period  of  months  is  in  intelligent  hands  capable  in  the  less 
resistant  cases  of  restoring  the  foot  to  its  normal  mobility  and  position, 
after  which  retention  treatment  should  be  begun.  The  method,  how- 
ever, is  too  tedious  and  uncertain  to  be  relied  upon. 

Plastcr-of-Paris  Bandages. — Another  method  in  correcting  club- 
foot  is  by  repeated  fixation  in  a  plaster-of-Paris  bandage,  the  foot 


TALIPES 


355 


being  held  as  nearly  in  a  corrected  or  in  an  overcorrected  position 
as  possible  at  each  application  of  the  bandage  until  the  bandage 
hardens.  The  application  of  a  plaster-of-Paris  bandage  must  be  made 
with  care  and  skill  to  prove  efficient. 

The  foot  should  be  wound  with  sheet  wadding,  pads  should  be 
temporarily  placed  between  the  toes,  and  the  foot  should  be  held  over- 


FIG.  320. — Congenital   Double   Club-        FIG.   321. — Double   Club-foot.      Two   mon 
foot  Walking  Before   Operation.  tion    by    forcible   manipulation,    wearini 

tive  appliances.      Same  case  as  Fig.  32 


Two   months   after  correc- 
"<'        walking   reten- 


120. 


corrected,  with  the  knee  flexed,  from  the  first  during  the  application 
of  the  bandage  by  an  assistant,  who  shifts  the  fingers  from  place  to 
place  to  keep  out  of  the  way  of  the  bandage,  yet  who  maintains  the 
overcorrection. 

The  circulation  of  the  toes  must  be  carefully  watched  after  the 
application  of  such  a  bandage. 


356 


ORTHOPEDIC  SURGERY 


The  bandage  should  reach  above  the  knee,  where  the  limb  should 
be  bent  to  prevent  the  plaster  bandage  ( which  should  be  renewed 
every  two  or  three  weeks)  from  rolling  around  the  limb,  and  to 
prevent  the  child  from  kicking  it  off.  In  the  case  of  small  children 


FIG.   3J2. — Double  Club-foot   in    Plaster   Bandages   After   Operative   Correction. 

with  plump  legs,  and  in  resistant  cases,  it  will,  however,  be  found 
difficult  to  prevent  the  heel  from  being  drawn  away  from  the  bandage, 
and  stretching  of  the  tendo  Achillis  will  by  this  method  be  tedious. 

This  method  has  the  disadvantage  of  being  tedious,  except  in  young 
children;  but  it  has  many  advantages  in  being  a  practical  method, 
readily  applied,  and  not  leaving  details  of  application  to  the  patient's 
parents.  It  is  evident  that  correction  in  this  way,  if  persistently  ap- 
plied, is  possible,  but,  except  in  very  young  children,  it  is  advisable 
to  perform  tenotomy  first.  If  the  Chinese  can  produce  an  extreme 
deformity  by  bandaging  the  children's  feet,  the  same  method  could  be 
employed  for  the  correction  of  deformity.  It  is  especially  adapted 
to  the  deformity  in  infants  under  4  months  of  age.  The  plaster 
bandage  can  be  protected  from  softening  by  urine  by  painting  it  when 
dry  with  jap-a-lac  paint. 

Apparatus. — Mechanical  correction  (without  tenotomy)  by  means 
of  appliances  has  been  successfully  employed  in  very  young  cases. 


TALIPES 


357 


The  method,  however,  requires  much  persistence  on  the  part  of  the 
surgeon  if  a  perfect  cure  is  expected,  and  is  not  to  be  advised. 

Although  treatment  by  apparatus  is  not  sufficiently  effective  to 
cure  any  but  the  mildest  forms  of  congenital  club-foot  in  young  chil- 
dren, it  is  often  enough  to  bring  about  a  cure  in  acquired  club-foot  of 
moderate  severity.  The  form  of  apparatus  is  the  same  whether  used 
as  a  corrective  or  as  a  retentive  appliance,  and  will  be  described  here. 
The  object  of  such  apparatus  is  to  retain  the  tarsal  bones  in  proper 


FIG.  323. — Splint  for  Club-feet,  Inner  and  Outer  Views. 

position  until  the  muscles  and  ligaments  have  adapted  themselves  to 
the  normal  position,  and  until  articular  facets  have  been  formed  in 
the  proper  direction,  or  the  astragalus  and  os  calcis  have  assumed, 
under  altered  pressure,  a  relatively  normal  shape. 

The  corrected  foot  tends  to  relapse  in  two  directions — inversion 
and  elevation  of  the  heel.  If  this  is  unchecked  and  walking  is  done 
in  improper  attitudes,  hurtful  pressure  and  strain  fall  upon  the  bones 
and  ligaments  of  the  foot,  and  relapse  takes  place.  This  should  not 
occur  if  proper  retention  and  walking  with  a  proper  attitude  of  the 
foot  are  cared  for. 

As  these  appliances  are  to  be  worn  a  long  time,  they  should  be 
light,  readily  adjusted  by  the  nurse,  not  unsightly,  and  in  no  \vay 
limiting  locomotion,  walking,  or  running.  The  best  are  worn  within 
the  shoe. 


358 


ORTHOPEDIC  SURGERY 


It  is  to  be  remembered  that  in  all  appliances  it  is  necessary  that 
the  pressure  preventing  a  faulty  position  of  the  foot  should  be  applied 
precisely,  pressing  the  front  of  the  foot  and  the  inner  tip  of  the  heel 
outward,  the  front  of  the  foot,  especially  the  outer  edge  including 
the  cuboid,  upward,  and  the  back  sole  (i.e.,  the  end  of  the  os  calcis) 
downward. 

Inward  pressure  should  be  exerted  upon  the  outer  edge  of  the  front 
of  the  os  calcis  and  astragalus,  and  not  upon  the  cuboid,  as  is  too 


FIG.   324. — Splints   for   Equino-varus  Applied. 


commonly  done  in  inefficient  apparatus.  As  the  latter  bone  is  in  front 
of  the  mediotarsal  joint,  inward  pressure  upon  it  not  only  fails  to 
correct  the  deformity  but  tends  to  increase  it.  This  explains  the  oc- 
currence of  many  relapses,  faulty  apparatus  being  not  only  useless 
but  injurious. 

The  apparatus,  which  is  a  modification  of  Taylor's  varus  shoe, 
consists  of  a  sole  plate  small  enough  to  fit  in  a  shoe  secured  to  a 


TALIPES 


359 


jointed  upright  furnished  with  a  stop  to  prevent  the  plate  from  drop- 
ping into  the  equinus  position.  The  foot  is  secured  to  the  plate  by 
means  of  straps. 

The  appliance  can  be  worn  inside  of  a  shoe,  opened  like  a  bicycle 
shoe  well  down  to  the  toes. 

OPERATIVE  TREATMENT. — A  combination  of  operative  and  me- 
chanical methods  of  treatment  is  at  present  the  most  common  mode  of 
treating  club-foot  at  all  ages,  apparatus  being  used  after  overcorrec- 


FIG.  325. 


FIG.  326. 


FIG.  325. — Imprint  of  Foot  of  a  Child  Sixteen  Years  Old.     Treated  when  one  year  old  for  con- 
genital club-foot. 
FIG.  326. — Imprint  of  Normal  Foot. 

tion  has  been  obtained  as  a  means  of   retention   until  the  normal 
muscular  balance  has  been  restored.    The  operative  interference  most 
.frequently  resorted  to  is  tenotomy  and  subcutaneous  division  of  the 
fasciae  or  ligaments. 

Tenotomy. — The  structures  to  be  divided  are,  of  course,  those 
which  hold  the  foot  in  its  deformed  position.  The  tendons  may  be 
divided  by  entering  the  tenotome  under  the  skin  and  cutting  the 
tendon  from  without  inward,  or  by  passing  the  tenotome  under  the 
tendon  and  cutting  outward.  The  advantage  of  the  former  is  that 
there  is  no  danger  of  making  a  large  skin  incision  by  a  slip  of  the 
tenotome.  There  is,  however,  danger  of  incomplete  cutting  of  the 


3Co  ORTHOPEDIC  SURGERY 

tendon.     The  tendon   which   is  most   frequently  divided   in  equino- 
varus  is  the  tendo  Achillis. 

Section  of  the  Tendo  Achillis. — The  patient  should  lie  upon  his 
face  or  side  and  an  assistant  should  hold  the  foot ;  the  surgeon  enters 
the  knife  parallel  to  the  border  of  the  tendon,  passing  the  tenotome 


FIG.  327. — Relapsed   Resistant   Congenital   Club-foot   in   a   Boy   of   Eight.      Front  view. 

flatwise  between  the  tendon  and  the  skin.  This  having  been  done, 
the  blade  of  the  knife  is  turned  toward  the  posterior  surface  of  the 
tendon  and  the  assistant  raises  the  end  of  the  foot  so  as  to  stretch 
the  tendo  Achillis  slightly.  The  left  index  finger  presses  on  the  skin 
over  the  back  of  the  tenotome,  and  in  this  way  the  sensation  of  the 
cutting  of  the  tendon  can  be  felt. 

The  only  precaution  necessary  is  to  be  assured  that  the  tendon  is 
completely  divided.  \Yhen  the  operation  is  done,  the  extravasated 
blood  is  squeezed  out  of  the  opening  and  a  small  amount  of  aseptic 
gauze  is  placed  over  the  wound.  The  operation  should  be  done 
aseptically  and  an  aseptic  dressing  applied. 


TALIPES 


361 


In  older  cases,  especially  in  paralytic  equinns,  the  tendon  can  be 
half  divided  at  two  levels,  one  on  the  inner  and  the  other  on  the 
outer  part,  and  the  rest  of  the  tendon  torn  by  manipulative  force.  A 
lapping  flap  may  thus  be  secured,  facilitating  more  rapid  develop- 
ment of  a  strong  tendon. 


FIG.  328. — Relapsed  Resistant  Congenital  Club-foot  in  a  Boy  of  Eight.      Rear  view. 

The  insertions  of  the  tendons  of  the  tibialis  anticus  and  posticus 
muscles  can  be  divided,  and  at  the  same  time  the  shortened  ligaments 
on  the  inner  and  under  side  of  the  articulation  between  the  astragalus 
and  scaphoid  by  a  free  use  of  the  tenotome  inserted  at  the  inner  side 
of  the  astragalo-scaphoid  articulation.  If  the  point  and  edge  of  the 
tendon  is  kept  close  to  the  bone  there  is  little  danger  of  serious  injury 
to  the  artery.  • 

Division  of  the  Plantar  Fascia. — It  is  often  necessary  to  divide  also 
the  plantar  fascia,  preferably  before  division  of  the  tendo  Achillis, 
as  the  latter  acts  as  a  means  of  support  for  stretching  the  foot  when 


362 


ORTHOPEDIC  SURGERY 


the  plantar  fascia  is  divided.  The  plantar  fascia  is  divided  in  the 
same  way  that  the  tendons  are  incised.  The  most  prominent  portion 
of  the  fascia  is  the  point  of  election  for  subcutaneous  incision.  The 
fascia,  it  must  be  borne  in  mind,  is  not  a  narrow  band,  but  a  broad 
ligament  needing  a  long  subcutaneous  incision.  The  tenotome  should 
be  inserted  on  the  inner  side  of  the  sole  nearly  halfway  between  the 
os  calcis  and  the  ball  of  the  foot,  but  nearer  to  the  os  calcis.  The 


FIG.  329. — Same    Case.       Three    weeks    after    forcible    correction,    immediately    after    removal    of 

plaster  retention  bandages. 

tenotome  is  to  be  pushed  subcutaneously  nearly  across  the  sole,  the 
edge  of  the  knife  turned  toward  the  fascia,  and  the  knife  drawn  across 
the  fascia,  which  will  be  felt  to  give  way  as  it  is  divided ;  an  assistant 
should  make  upward  pressure  upon  the  ball  of  the  foot,  in  order  to 
put  the  fascia  on  the  stretch.  As  the  artery  lies  deeply,  there  is  no 
danger  of  injuring  it,  if  ordinary  care  is  used. 

The  tenotomes  used  should  be  strong  at  the  neck,  and  the  cutting 
edge  should  not  be  too  long,  as  the  skin  is  necessarily  divided  if  they 
are  too  long;  infantile  cases  require  a  much  smaller  instrument.  The 
blunt-pointed  tenotome  is  but  little  used  now,  and  the  sharp-pointed 
ones  are  used  for  all  subcutaneous  work. 

Tenotomes  as  furnished  by  instrument-makers  are  ordinarily  much 


TALIPES 


363 


too  large,  and  though  serviceable  in  myotomy,  are  better  for  tenotomy 
in  children  if  smaller. 

The  Repair  of  Divided  Tendons. — When  a  tendon  is  divided,  the 
cut  ends  are  separated  to  a  variable  extent,  depending  upon  the  retrac- 
tion of  the  muscle  to  which  it  belongs ;  but  a  strong  tendon  results  by 
natural  repair  if  the  sheath  has  not  been  extensively  injured  by  the 
tenotomy. 

The  calcaneo-cuboid  ligament  should  also  be  divided  in  severe 
cases.  The  tenotome  should  be  inserted  a  short  distance  behind  the 


FIG.  330. — Soles  of  Relapsed  Resistant  Congenital  Club-foot  in  a  Boy  of  Eight. 


head  of  the  fifth  metatarsal  bone,  near  the  articulation  of  the  os  calcis 
and  cuboid,  which  can  be  felt  on  palpation.  The  sharp-pointed 
tenotome  should  be  inserted  to  the  bone,  and  then  by  careful  motion 
the  whole  ligament  should  be  divided. 

In  case  the  correction  has  not  been  perfect,  as  sometimes  happens 
with  more  resistant  feet,  a  second  operative  correction  is  necessary. 

When  the  plaster  bandages  are  removed  the  retention  appliance, 
described  above,  is  to  be  used  so  long  as  there  is  any  tendency  to  an 
incorrect  position. 

The  permanence  of  the  correction  depends  on  the  establishment  of 
an  accurate  balance  of  the  antagonism  of  muscles  and  other  soft  parts 
when  the  foot  is  in  normal  position.  The  after-treatment  by  retention 
must  be  persisted  in  until  the  child  is  able,  without  special  effort,  to 


364 


ORTHOPEDIC  SURGERY 


walk  with  the  foot  in  a  natural  position ;  otherwise  a  relapse  will 
occur. 

The  use  of  retention  apparatus  will  be  necessary  for  some  time 


FIG.  331.- — Thomas  Club-foot  Wrench,  Modified.      (Hoffa.) 

and  should  be  discontinued  gradually.  The  parent  may  aid  in  the 
treatment  by  daily  manipulating  the  feet  into  the  overcorrected  posi- 
tion. 

OPERATIVE  CORRECTION. 

In  cases  too  resistant  to  be  corrected  by  the  means  described  the 
following  radical  measures  may  be  employed : 

i st.  Open  incision. 

2d.  The  use  of  extreme  force. 

3d.  Tarsal  osteotomy. 

OPEN  Ixcisiox. — The  chief  difficulty  is  in  obstinate  cases  to 
stretch  the  contracted  tissue  on  the  concave  side  of  the  distortion. 
Phelps'  open  incision  on  the  inner  and  plantar  surface  is  of  use  in 
these  cases. 


TALIPES 


365 


The  advantage  of  open  incision  in  club-foot  is  the  facility  of 
complete  and  thorough  division  of  all  the  soft  tissues  to  the  bone. 
The  method  by  which  this  is  done  is  as  follows :  The  skin  is  divided 
along  the  inner  side  of  the  foot,  from  the  tip  of  the  malleolus  well 


FIG.   332. — Manipulative  Correction  of  Club-foot.      (After  Lor;nz.) 

down  on  the  inner  edge  of  the  first  metatarsal  bone.  After  the  skin 
is  incised,  the  other  tissues  are  cut  with  care,  using  a  director  if  neces- 
sary. The  insertion  of  the  tibialis  tendon  is  found  and  cut  across. 
The  artery  can  be  spared  by  careful  dissection,  but  if  necessary  it  can 


FIG.  333. — Lever  Correction  Apparatus  Applied. 

be  divided  and  tied.  The  plantar  fascia  on  the  sole  of  the  foot  should 
be  divided  by  the  use  of  a  tenotome,  or  long,  thin  knife.  A  cross 
incision  toward  the  sole  of  the  foot  from  the  middle  of  the  long 
incision  is  sometimes  necessary,  but  it  is  desirable  to  avoid  this  if 
possible.  A  triangular  incision  with  its  apex  upward  toward  the 
ankle,  instead  of  the  cross-cut  of  the  skin  and  fascia,  is  equally  ef- 
ficient and  diminishes  the  gap  after  correcting  the  foot. 

FORCIBLE  MANIPULATION. — Even  if  tenotomy  and  thorough  open 
incision  are  done,  a  certain  amount  of  resistance  remains  from  the 


366 


ORTHOPEDIC  SURGERY 


interosseous  ligament  connecting  the  tarsal  bones.  Considerable  force 
is  often  necessary  to  bring  the  foot  into  an  overcorrected  position. 
This  can  be  done  either  by  manual  force  or  by  the  aid  of  mechanical 
force.  Several  wrenches  for  this  purpose  have  been  devised;  that  of 


FIG.   334. — Double   Congenital   Club-foot   Before   Operation. 


Thomas  is  the  simplest  and  is  sufficiently  efficient  when  no  bone  ob- 
struction exists.  The  foot  is  then  brought  into  an  overcorrected 
position,  thorough  aseptic  dressings  are  applied,  and  the  foot  is 
then  fixed  in  a  plaster-of -Paris  bandage  reaching  above  the  knee  and 
holding  the  well-padded  and  aseptically  dressed  foot  in  an  overcor- 
rected position.  If  the  dressing  is  provided  with  efficient  protectors 
and  sufficient  dressings,  no  change  in  the  bandage  need  be  made  for 
a  fortnight  or  longer.  If  necessary,  however,  a  window  can  be  cut 
in  the  plaster  over  the  wound  and  the  dressings  changed.  After  the 
plaster-of-Paris  is  discarded  the  retention  shoe  is  to  be  worn. 


TALIPES  367 

In  applying  the  bandages,  it  is  of  course  important  that  the  foot 
should  be  held  in  an  overcorrected  position  until  the  plaster  becomes 
hard,  as  no  further  correction  can  take  place  under  the  bandage.  In 
the  majority  of  cases  overcorrection  is  possible,  and  the  foot  can  be 
held  in  proper  position  for  the  application  of  the  fixation  bandage 
without  much  force. 

OSTEOTOMY. — When  but  a  slight  amount  of  osseous  distortion  is 
present  forcible  correction  aided  by  tenotomy  or  open  incision  will 


FIG.  335. — Same  Case  Six  Weeks  After  Operation  by  Forcible  Correction. 

be  sufficient  to  overcome  the  deformity,  but  in  the  more  resistant  cases 
changes  in  the  shape  of  the  tarsal  bones  forming  the  mediotarsal 
joint  prevent  perfect  cure,  and  operation  upon  the  bones  is  necessary. 

Astragaloid  Osteotomy. — An  examination  of  the  anatomy  of  re- 
sistant club-foot  shows  that  the  facet  of  the  astragalus  in  the  astragalo- 
scaphoid  articulation  is  on  the  side  instead  of  in  front.  There  is  also 
some  obliquity  of  the  neck  of  the  astragalus.  If  this  obstruction  of 
the  bone  can  be  corrected  and  the  front  of  the  foot  brought  into 
place,  there  would  be  less  tendency  to  relapse. 

It  is  essential,  in  every  inveterate  case  of  club-foot,  that  if  the 
foot  is  to  be  unfolded,  the  shortened  tissues  in  the  arch  of  the  foot  and 


368  ORTHOPEDIC  SURGERY 

in  the  inner  side  of  the  foot  must  be  stretched,  torn,  or  divided.  This 
can  be  done  safely  by  means  of  tenotomy,  forcible  stretching,  or  open 
incision ;  but  the  deformity  of  the  astragalus  still  remains.  In  many 
cases  of  younger  children,  even  if  somewhat  resistant,  if  the  deform- 
ity is  rectified  and  the  foot  held  a  sufficient  time  in  the  proper  posi- 
tion, and  a  proper  walking  shoe  used  for  a  year,  a  new  facet  of  the 
astragalus  will  be  formed  and  a  cure  effected.  In  a  few  cases  this 
is  not  the  case,  and  in  such  instances  osteotomy  of  the  neck  of  the 
astragalus  suggests  itself  as  a  suitable  operation. 

The  procedure  will  not  be  found  a  difficult  one.  Tenotomy  or  open 
incision  and  division  of  the  fascia  and  ligaments  should  be  done,  and 
the  foot  stretched  and  manipulated  into  as  nearly  normal  a  position 
as  possible.  An  incision  through  the  skin  is  made  from  the  tip  of 
the  malleolus  to  the  inner  side  of  the  head  of  the  first  metatarsal, 
•which  will  be  found  in  severe  cases  close  to  the  malleolus.  The  incision 
is  close  to  and  nearly  parallel  to  the  tibialis  anticus  tendon,  and  in 
the  direction  of  the  metatarsal.  The  incision  should  be  made  to  the 
bone  and  the  foot  straightened,  as  the  metacarpal  bone  is  separated 
from  the  malleolus.  The  scaphoid  will  be  seen  before  the  astragalus 
is  encountered,  if  the  deformity  is  great,  and  it  will  be  first  within 
the  reach  of  the  knife  in  all  cases.  If  the  foot  is  still  further  stretched, 
the  scaphoid  begins  to  uncover  the  side  of  the  astragalus,  and  the 
neck  of  the  astragalus  is  seen ;  a  small  osteotome  is  entered  and  placed 
upon  the  neck  of  the  astragalus,  to  the  proximal  side  of  the  scaphoid 
articulation,  and  the  neck  of  the  astragalus  divided  or  nearly  divided. 
The  foot  is  then  forcibly  straightened,  and  the  neck  of  the  astragalus 
unchiselled  is  fractured.  The  result  is  similar  to  that  in  Macewen's 
operation  for  knock-knee,  and  the  distortion  at  the  neck  of  the 
astragalus  is  removed.  It  is  manifest  that  the  line  of  section  of  the 
bone  at  the  neck  of  the  astragalus  should  be  transverse  to  the  axis 
of  the  bone,  and  at  such  a  plane  that  when  the  equinus  deformity  is 
corrected  the  resulting  gap  at  the  section  should  not  be  greater  than 
necessary.  The  foot  should  be  fixed  in  an  overcorrected  position.  A 
wedge-shaped  resection  of  the  neck  of  the  astragalus  through  a  skin 
incision  in  the  outer  and  upper  surface  of  the  foot  has  been  performed, 
but  linear  osteotomy  would  seem  to  be  preferable. 

Osteotomy  of  the  Head  of  the  Os  Calcis. — The  relation  of  the 
cuboid  to  the  os  calcis  is  frequently  masked,  lying  deeper  than  that 
of  the  scaphoid  and  astragalus,  and  it  may  in  treatment  be  but  par- 
tially corrected.  The  distortion  of  the  os  calcis  at  its  anterior  aspect, 
if  not  corrected,  increases,  and  forms  an  obstacle  to  the  complete 


TALIPES  369 

restoration  of  the  cuboid  to  the  normal  position,  although  the  rest  of 
the  deformity  may  have  been  corrected. 

When  the  cuboid  is  cartilaginous  and  the  ligaments  are  well 
stretched,  the  defect  at  the  anterior  portion  of  the  os  calcis  can  be 
overcome  bv  forcibly  correcting  the  foot  and  retaining  it  in  the  overcor- 
rected  position  bv  means  of  a  plaster-of-Paris  bandage,  care  being 
taken,  however,  that  the  cuboid  be  restored  to  place,  and  in  time  it 


FIG.  336. — Case  of  Bad  Relapsed  Congenital  Club-foot  in  a  Woman  of  Thirty-four,  Corrected 
by  Force  with  the  use  of  a  Wrench.  Photograph  taken  three  months  after  correction, 
showing  cicatrix  of  the  tear  of  the  skin  caused  by  correction. 

will  be  found  that  the  cartilaginous  abnormality  in  the  shape  of  the 
os  calcis  is  gradually  changed  under  corrected  pressure. 

When  distortion  of  the  head  of  the  os  calcis  is  great,  no  amount  of 
mechanical  treatment  can  overcome  the  obstacle,  if  it  is  of  bone  and 
if  the  ligaments  are  strong,  binding  the  bones  in  a  distorted  position. 
It  is  manifest  under  these  circumstances  that  the  rational  treatment  is 
a  removal,  not  of  the  astragalus  or  cuboid,  but  of  a  part  of  the  pro- 
jecting portion  of  the  head  of  the  os  calcis. 

After  complete  stretching  or  division  by  tenotomy,  force,  or  open 
incision  of  the  contracted  tissues  on  the  inner  and  under  side  of  the 
foot,  tendons,  ligaments,  and  fasciae,  if  it  is  found  that  the  front  of 
the  foot  cannot  be  brought  to  a  perfectly  corrected  or  overcorrected 
position,  an  incision  should  be  made  on  the  outer  side  of  the  foot, 


370  ORTHOPEDIC  SURGERY 

passing  from  behind  the  external  malleolus  forward  and  downward. 
The  incision  should  be  a  curved  one,  and  the  chief  convexity  should  be 
at  the  forward  portion  of  the  os  calcis.  This  incision  should  reach  to 
the  bone  and  should  expose  the  peroneal  tendons.  These  can  either 
be  drawn  to  the  side  or  divided  to  be  stitched  later.  The  upper  por- 
tion of  the  incision  should  reach  behind  the  external  malleolus,  and 
should  extend  far  enough  up  to  allow  sufficient  retraction  of  the  flap 
to  give  room  for  the  osteotomy.  After  the  bone  has  been  reached, 
and  the  periosteum  divided  and  pushed  aside,  an  osteotome  should  be 
inserted  far  enough  back  to  remove  a  sufficient  amount  of  bone. 
The  direction  of  the  insertion  of  the  osteotome  should  be  such  as  to 
allow  the  placing  of  the  cuboid,  after  the  bone  has  been  removed,  in 
a  normal  position.  This  step  of  the  operation  requires  some  nicety 
and  judgment,  as  it  is  of  importance  that  the  front  plane  of  the  bone, 
after  the  wedge  has  been  removed,  should  be  in  the  direction  of  the 
normal  facet  of  the  front  of  the  os  calcis.  A  wedge-shaped  portion 
of  bone  should  be  removed  from  the  anterior  and  outer  part  of  the 
os  calcis,  and  the  cartilaginous  ends  saved  in  order  to  allow  a  proper 
amount  of  motion  between  the  cuboid  and  the  os  calcis  after  recovery. 
The  wedge-shaped  portion  of  bone  that  should  be  removed  should  be 
ample  and  enough  to  allow  the  replacement  of  the  front  of  the  foot 
in  a  normal  or  overcorrected  position  and  the  restoration  of  the  proper 
direction  of  the  os  calcis. 

The  wound  should  be  carefully  washed  out  to  remove  any  frag- 
ments of  bone  that  may  have  been  left,  and  subsequently  stitched; 
the  tendon  of  the  peroneus  longus,  if  divided,  being  stitched.  The 
foot  should  then  be  dressed  with  proper  dressings  and  fixed  in  an 
overcorrected  position  by  plaster  bandages  according  to  the  ordinary 
rules  in  osteotomy. 

\Yhether  or  not  this  operation  should  be  done  in  connection  with  an 
osteotomy  of  the  neck  of  the  astragalus,  and  with  an  open  incision, 
is  a  matter  of  judgment. 

Imperfect  results  are  due  to  neglect  of  thorough  asepsis,  failure 
to  remove  a  sufficient  amount  of  bone,  failure  to  remove  it  in  such 
a  direction  as  to  cure  the  deformity,  and  lack  of  care  in  placing  the 
foot  in  an  overcorrected  position  after  operation. 

\Yhile  the  plaster  is  hardening  the  cuboid  is  pressed  upward  and 
outward,  and  the  front  of  the  foot  pressed  outward  and  upward, 
counter-pressure  being  applied  on  the  astragalus  on  the  outer  and 
upper  side,  and  the  os  calcis  twisted  into  its  normal  position. 

Treatment  can  be  carried  out  with  a  plaster-of-Paris  bandage  until 


TALIPES  371 

the  foot  is  thoroughly  healed,  and  also  until  locomotion  has  been 
re-established.  After  this  the  use  of  the  club-foot  shoe  is  advisable  for 
at  least  some  months. 

RELAPSES. — No  error  is  greater  than  a  common  one,  namely, 
that  tenotomy  is  sufficient  to  cure  club-foot.  In  fact,  tenotomy  is 
only  the  beginning  of  a  course  of  treatment.  If  the  foot  is  rectified 
and  held  in  place  for  a  month,  it  is  supposed  by  some  surgeons  that 
a  cure  has  been  effected.  But  such  is  by  no  means  the  case. 

Moreover,  it  must  always  be  borne  in  mind  that  relapses  will 
invariably  occur  unless  the  distortion  is  overcorrected,  and  little  reli- 
ance can  be  placed  on  the  curative  effect  of  time.  Efforts  at  correction 
should  be  continued  until  the  foot  can  be  easily  abducted  beyond  the 
median  line,  and  while  slightly  abducted,  can  be  flexed  so  that  the  dor- 
sum  of  the  foot  shall  form  less  than  a  right  angle  with  the  leg,  the 
sole  of  the  foot  being  flat,  and  there  being  no  twist  in  the  front  of 
the  foot.  After  this  the  correction  appliance  can  be  gradually  omitted 
while  manipulation  of  the  foot  is  still  carried  on,  and  the  case  should 
be  kept  under  observation. 

Relapses  occur  in  a  certain  number  of  cases  simply  from  the  care- 
lessness of  the  parents,  who  are  not  aware  of  the  necessity  of  retain- 
ing the  corrected  foot  in  the  proper  position  for  a  long  time.  In  such 
cases  a  second  operation  is  advisable. 

Relapses  in  older  children  are  due  to  incomplete  correction,  either 
from  a  lack  of  thoroughness  or  from  the  existence  of  an  unusual 
amount  of  distortion  of  the  astragalus  or  os  calcis  not  suspected,  and 
demanding  osteotomy,  or  from  too  early  removal  of  the  fixation  or 
retention  appliance. 

In  some  instances  of  resistant  club-foot  it  is  found  difficult,  in 
correcting  the  foot,  completely  to  overcorrect  the  equinus  deformity, 
and  to  enable  the  foot  to  be  brought  to  within  a  right  angle  with  the 
leg.  If  this  is  not  done,  inconvenience  is  felt  by  the  patient  in  taking 
a  long  step,  and  the  foot  is  turned  in  to  facilitate  this.  The  smaller 
the  foot  the  greater  this  danger.  If  this  is  not  corrected,  it 
may,  in  some  instances,  seriously  interfere  with  the  excellence  of  the 
result. 

It  should  always  be  borne  in  mind  that  a  distortion  in  the  neck  of 
the  astragalus  or  in  the  head  of  the  os  calcis  exists,  even  in  infantile 
club-foot,  and  that  the  feet  are  not  permanently  corrected  until  the 
alteration  of  the  facets  into  a  normal  position  has  taken  place.  This  is 
independent  of  bringing  the  foot  into  a  normal  position,  and  demands 
fixation  in  an  overcorrected  position  for  some  time.  In  some  cases 


3/2  ORTHOPEDIC  SURGERY 

this  is  more  needed  than  in  others,  probably  because  the  alterations  of 
the  facets  of  the  astragalus  are  in  some  instances  slight. 

Too  great  overcorrection  of  the  deformity  and  the  development 
of  a  splay-foot  have  sometimes  resulted  from  overzealous  treatment. 
This  danger  is.  however,  not  great;  and  instances  are  rare,  and  are 
to  be  overcome  by  the  treatment  for  a  valgus  foot. 

Inversion  of  the  foot,  after  cure  of  the  club-foot,  may  in  a  few 
instances  be  observed  from  imperfect  strength  of  the  outward  rotatory 
muscles  at  the  hip.  This,  however,  causes  but  little  disfigurement, 
the  inversion  usually  being  slight,  and  correcting  itself  by  the  normal 
development  of  the  muscles.  A  marked  toeing-in  of  the  foot  in  run- 
ning persists  a  long  time  in  some  instances  in  which  the  foot  is 
entirely  corrected  and  the  walking  is  normal.  It  disappears  with  the 
increase  of  muscular  strength.  In  such  cases  the  ordinary  Taylor  shoe 
should  be  carried  up  to  the  hip  by  means  of  an  upright  on  the  outside 
of  the  leg  and  a  posterior  arm  carried  back  from  the  level  of  the 
trochanter,  as  in  the  knock-knee  splint.  By  tightening  this,  eversion 
is  secured. 

A  relaxed  state  of  the  knee-joint  causing  inversion  of  the  tibia 
is  not  uncommon  in  infantile  club-foot:  it  usually  corrects  itself  in 
the  development  of  the  child  after  correction  of  the  foot.  In  rare 
instances,  however,  it  may  persist,  requiring  the  longer  use  of  a  walk- 
ing appliance. 

The  muscles  retarded  in  club-feet  by  disuse  need  development  be- 
fore a  complete  cure  is  effected.  Ordinarily  the  muscles  develop  of 
themselves  after  complete  correction,  if  the  limbs  are  actively  used. 
In  some  cases  the  development  is  slow  and  massage  and  electricity 
are  advisable. 

In  addition  to  retentive  appliances,  in  cases  of  imperfect  muscular 
balance,  shoes  (worn  over  the  appliance,  if  necessary)  with  a  high 
sole  wedge  under  the  cuboid  are  sometimes  needed.  This  corrects  at 
each  step,  as  the  weight  comes  upon  the  sole,  the  dropping  of  the 
cuboid. 

The  most  common  form  of  acquired  talipes  equino-varus  is  that 
following  infantile  paralysis. 

The  correction  of  paralytic  club-foot  is  to  be  conducted  on  the 
same  principles  as  that  of  the  congenital  type.  Correction  is,  however, 
much  less  difficult,  as  osseous  changes  are  present  only  in  the  old 
severe  and  neglected  cases. 

Tenotomy  of  the  contracted  muscles  can  be  done  as  in  congenital 
cases,  though  overcorrection  after  tenotomy  is  to  be  avoided.  Imme- 


TALIPES 


373 


diate  correction  and  fixation  in  a  corrected  position  are  to  be  used 
after  tenotomy  as  in  the  congenital  form. 

In  paralytic  equino-varus,  tendon  transference,  referred  to  under 
infantile  paralysis,  is  of  importance,  and  arthrodesis  or  silk  ligaments 
in  older  cases. 

TALIPES    EQUINUS. 
(Pes  equinus,  Horse  heel,  Pied  bot  equin,  Pferdefuss,  and  Spitzfuss.) 

Talipes  equinus  is  the  name  given  to  a  condition  in  which  the  foot 
is  held  in  a  position  of  plantar  flexion  and 
cannot  be  dorsally  flexed  to  the  normal 
extent    (twenty   degrees  beyond  a   right 
angle). 

Varieties. — Talipes  equinus  may  be 
congenital  or  acquired.  Congenital  equi- 
nus is  an  uncommon  deformity,  con- 
stituting about  five  per  cent  of  all  cases 
of  equinus. 

In  the  acquired  forms  all  degrees  of 
deformity  are  met,  from  the  slight  condi- 
tion in  which  the  foot  cannot  be  flexed 
dorsally  beyond  a  right  angle  with  the  leg, 
to  one  in  which  the  foot  and  leg  form 
practically  a  straight  line. 

Etiology. — The  causes  of  acquired 
talipes  equinus  are  as  follows:  Infantile 
paralysis  of  the  anterior  muscles  of  the 
leg.  Cerebral  (spastic)  paralysis.  Short- 
ening of  the  leg  after  joint  disease  or  frac- 
ture may  lead  to  an  adaptive  talipes 
equinus  which  serves  to  make  the  legs  of 
equal  length  for  walking. 

Talipes  equinus  may  be  a  symptom  or 
result  of  disease  of  the  ankle-joint.  Long 
confinement  to  bed  may  cause  talipes 
equinus,  which  is  merely  the  result  of  the 
long-continued  plantar  flexion  of  the  foot. 

Fractures  may  result  in  talipes  equinus  either  from  injury  to  the 
ankle-joint  or  from  fixation  during  repair  in  a  plantar-flexed  position. 

The  contraction  caused  by  posterior  cicatrices  or  the  loss  of  power 
due  to  division  or  injury  of  the  anterior  muscles  and  tendons  of  the  leg. 


FIG.  337. — Talipes  Kquinus  of 
Marked  Degree.  This  represents 
the  weight-bearing  position. 


374 


ORTHOPEDIC  SURGERY 


Symptoms. — The  deformity  in  its  slighter  degrees  is  not  particu- 
larly disabling.  In  its  severer  grades  it  is  the  cause  of  a  severe  limp 

and  at  times  of  much  discomfort. 

The  detection  of  talipes  equinus  is  a 
simple  matter.  The  normal  foot  should  be 
capable  of  flexion  about  twenty  degrees  be- 
yond a  right  angle,  and  any  cause  which 
restricts  this  flexion  is  a  degree  of  talipes 
equinus. 

Treatment. — The  division  of  the  tendo 
Achillis  will  relieve  the  deformity  in  all 
cases  except  those  in  which  bony  deformity 
exists  at  the  ankle,  as  in  the  cases  following 
fracture  and  tuberculosis  of  the  ankle-joint. 
In  such  cases  or  in  extremely  severe  in- 
stances of  deformity  from  other  causes, 
osteotomy  of  the  tarsus  may  rarely  be  re- 
quired for  rectification. 

The  deformity  should  be  at  once  cor- 
rected after  tenotomy  and  a  plaster-of-Paris 
bandage  applied.  If  a  retention  appliance 
is  required  after  operation,  a  modification  of 
the  club-foot  shoe,  with  the  ankle-joint  ar- 
stop  extension  at  a  right  angle,  will  be  found  to  be 
effective  and  simple. 

TALIPES   CALCANEUS. 

Talipes  calcaneus  is  the  name  applied  to  a  condition  in  which  the 
foot  is  held  in  a  position  of  dorsal  flexion. 

Varieties. — The  deformity  may  be  congenital  or  acquired. 

It  is  a  comparatively  rare  congenital  deformity,  the  form  ordi- 
narily seen  being  a  paralytic  calcaneus,  often  combined  with  a  valgus 
deformity. 

Symptoms. — The  patient  walks  upon  the  heel  and  the  gait  is  in- 
elastic, because  the  spring  of  the  foot  is  absent  and  the  patient  walks 
bearing  the  whole  weight  on  the  os  calcis. 

Treatment. — In  congenital  cases  the  foot  should  be  daily  manipu- 
lated by  the  parents  into  a  position  of  plantar  flexion.  As  soon  as 
the  anterior  muscles  are  stretched,  it  is  advisable  to  put  the  foot  up  in 
a  position  of  plantar  flexion,  to  bring  about  adaptive  shortening  of  the 
posterior  muscles.  In  the  severer  cases  the  application  of  a  series  of 


FIG.  338. — Apparatus  for  Talipes 
Kquinus,  with  Stop  Catch.  On 
the  Right  of  the  Picture  is  a 
Detail  Drawing  of  the  Stop 
for  Talipes  Calcaneus,  on  the 
Left  a  Catch  Allowing  Slight 
Motion. 


ranged   to 


TALIPES 


375 


corrective  plaster  bandages  holding  the  foot  in  plantar  flexion  may 
be  necessary.  Tenotomy  of  the  anterior  tendons  is  rarely  required. 
When  the  foot  can  be  plantar-flexed  to  the  normal  amount,  a  reten- 


FIG.  339. — Talipes   Equinus  of  Left   Foot   Resulting  from  Paralysis. 

tion  shoe  preventing  dorsal  flexion  may  be  applied,  but  in  slight  cases 
this  is  not  necessary.  The  foot  can  be  supported  in  a  splint  with  an 
upright  jointed  at  the  ankle,  but  with  a  stop  preventing  motion  of 
the  foot  upward,  or  by  prolonging  backward  the  heel  of  the  shoe. 
The  paralytic  form  is  discussed  under  Infantile  Paralysis. 

TALIPES   VALGUS. 

Talipes  valgus  is  the  name  given  to  a  condition  which  is  not  in  all 
cases  to  be  clearly  differentiated  from  what  has  been  described  as 
flat-foot.  Talipes  valgus  may  be  congenital  or  acquired.  As  a  con- 


3/6 


ORTHOPEDIC  SURGERY 


genital  deformity  it  is  one  of  the  less  common  of  the  congenital  de- 
formities of  the  foot. 

Acquired  Talipes  I'algns. — The  most  common  cause  of  acquired 
talipes  valgus,  not  of  the  purely  static  variety,  is  anterior  poliomyelitis. 
It  also  occurs  following  inflammation  of  the  ankle-joint,  and  in  cer- 


FIG.   340. — Talipes  Calcaneus. 


tain  cases  of  spasm  of  the  peroneal  muscles.  Treatment,  if  the  con- 
genital form,  consists  in  repeated  correction  by  plaster  bandages,  aided 
in  the  severer  cases  by  midtarsal  osteotomy.  In  the  paralytic  cases, 
after  correction  of  the  deformity,  muscle  transference  or  arthrodesis 
or  the  use  of  a  retention  shoe  is  needed. 

TALIPES    VARUS. 

Talipes  varus  is  the  name  given  to  a  condition  in  which  the  front 
of  the  foot  is  turned  inward. 

Treatment. — In  the  congenital  form  the  treatment  is  practically  the 
same  as  that  of  equino- varus,  except  that  it  is  not  necessary  to  cut  the 
tendo  Achillis.  In  the  acquired  form  retentive  apparatus  is  useful, 
preventing  inversion  of  the  foot. 

TALIPES    CAVUS. 

Talipes  cavus  (hollow  foot)  is  the  name  given  to  a  condition  in 
which  the  arch  of  the  foot  is  increased  and  the  anterior  part  of  the 
foot  is  approximated  to  the  heel.  It  is  not  necessarily  associated 


TALIPES 


377 


with  any  other  deformity,  but  may  occur  in  connection  with  talipes 
equinus,  calcaneus,  or  varus.  It  is  rarely  congenital  in  its  severe  forms, 
but  a  markedly  high  arch  to  the  foot  may  be  an  inherited  peculiarity 
sometimes  sufficiently  marked  to  justify  classing  it  as  pathological.  In 


FIG.  341.  -.Moderate    Degree   of  Talipes 
Valgus,  Right  Foot. 


FIG.  342. — Talipes  Yarus,   Right  Foot. 


.the  acquired  form  it  exists  in  most  cases  as  the  result  of  anterior  polio- 
myelitis, and  is  also  to  be  classed  as  a  shoe  deformity.  The  patho- 
logical changes  show  nothing  besides  the  effects  of  a  continued  mal- 
position of  the  bones.  The  deformity  varies  more  or  less  in  degree. 
The  most  marked  form  is  to  be  found  in  the  foot  of  the  Chinese  lady 
of  high  rank,  in  which  the  heel  and  front  of  the  foot  are  approxi- 
mated by  bandaging  in  early  youth,  and  a  degree  of  pes  cavus  is  in- 
duced which  does  not  exist  except  under  these  highly  artificial  condi- 
tions. From  this  extreme  grade  all  degrees  of  the  affection  are  seen, 


3/8 


ORTHOPEDIC  SURGERY 


the  slightest  being  an  increased  elevation  of  the  arch  not  accompanied 
by  symptoms,  in  which  the  foot  rests  upon  the  ground  in  standing, 
touching  only  on  the  heel  and  ball  of  the  foot.  It  is  less  disabling 
than  pes  calcaneus,  and  is  frequently  associated  with  the  other  de- 
formities mentioned.  The  two  types  commonly  seen  are,  first,  those 


FIG.   343.  —  PCS   Cavus  with   an   Element   of   Calcaneus. 


resulting  from  anterior  poliomyelitis,  in  which  a  paralysis  more  or 
less  extensive  has  involved  the  foot  and  leg.  In  a  second  form,  gen- 
erally milder  in  grade,  it  apparently  develops  as  a  shoe  deformity  in 
middle  childhood,  and  appears  to  be  the  result  of  wearing  too  short 
a  shoe  or  of  a  shoe  narrower  than  the  front  of  the  foot ;  the  front 
of  the  foot  being  held  back  by  the  front  of  the  boot,  the  tendency  in 
weight-bearing  is  to  approximate  the  heel  and  the  toe,  and  in  this  way 
to  approximate  the  front  of  the  foot  to  the  heel.  In  the  slightest 
grade  it  apparently  forms  one  of  the  varieties  of  the  condition  de- 
scribed as  contracted  foot.  The  plantar  fascia  is  contracted  and  bands 
may  be  felt  under  the  skin  and  passive  dorsal  flexion  of  the  foot  is 
often  limited  at  a  right  angle  or  more.  The  symptoms  in  the  slighter 
varieties  are  those  of  a  sprain  of  the  arch  of  the  foot  and  the  muscles 


TALIPES 


379 


of  the  leg,  owing  to  insecure  balance  of  the  foot  in  standing.  Corns 
and  callosities  may  develop  in  the  front  of  the  foot;  the  elasticity  of  the 
gait  is  impaired. 

The  treatment  of  the  slighter  forms  consists  in  the  use  of  a  boot 
with  sufficient  room  in  the  upper  and  a  sufficiently  high  shank.  If  any 
element  of  equinus  coexist,  the  tendo  Achillis  should  be  lengthened  by 
stretching  or  tenotomy.  Operation  is  required  in  the  severer  cases. 


FIG.  344. -Club-hand  due  to  Congenital  Absence  of  Radius.     (Sayre.) 

The  plantar  fascia  is  thoroughly  divided  by  a  subcutaneous  tenotomy, 
and  the  foot  is  forced  into  shape  by  means  of  an  osteoclast,  after  which 
•the  foot  is  put  up  in  a  plaster  bandage,  which  should  flatten  the  arch 
of  the  foot  as  much  as  possible.  When  walking  is  begun,  which  should 
be  as  early  as  possible  after  operation,  the  steel  sole  plate  and  strap 
described  in  speaking  of  pes  cavus  in  infantile  paralysis  should  be 
adjusted  to  the  shoe. 

PES  PLANUS. 

This  consists  of  an  abnormality  at  the  metatarso  coneiform  articu- 
lation, chiefly  of  the  first  metatarsus. 


380  ORTHOPEDIC  SURGERY 

It  is  frequently  seen  in  babies  and  is  not  uncommon  in  the  old 
and  feeble,  with  weakened  plantar  muscles.  It  is  of  little  pathological 
significance,  except  when  combined  with  a  valgtis  deformity  constitut- 
ing plano-valgus,  or  flat-foot,  referred  to  elsewhere. 


CLUB-HAND. 

In  German  the  distortion  is  known  as  Klumphand,  and  in  French 
as  main  bote. 

Congenital  club-hand  is  a  rare  condition,  analogous  to  congenital 
club-foot.  The  name  is  applied  to  a  deviation  of  the  hand,  at  the 
wrist,  from  the  line  of  the  forearm;  this  deviation  is  almost  always 
in  the  direction  of  flexion. 

It  may  occur  without  malformation  of  bones,  but  more  commonly 
they  are  deformed,  or  the  radius  may  be  wanting  wholly  or  in  part. 
The  carpus  may  be  normal,  or  incompletely  developed,  or  almost 
entirely  wanting.  \Yhen  the  radius  is  deficient,  the  lower  end  of  the 
ulna  is  enlarged  to  articulate  with  the  carpus. 

The  diagnosis  is  evident,  and  any  pathological  process  which  is 
accompanied  by  this  malposition  is  classified  as  club-hand. 

In  early  childhood  correction  should  be  attempted  by  repeated 
plaster  bandages. 

When  operation  is  attempted  in  older  cases  it  should  consist  in 
bone  plastic  attempts  to  supplement  an  absent  radius  by  splitting  the 
ulna  and  inserting  the  carpus  between  the  split  fragments. 

Treatment. — In  the  mildest  cases,  particularly  if  the  bony  struc- 
ture is  normal,  treatment  should  consist  of  manipulation  to  stretch 
the  contracted  tissues  and  retention  in  the  correct  position  by  means 
of  a  splint. 


CHAPTER  XIX. 
FLAT-FOOT. 

Definition. — The  term  "  flat-foot  "  is  applied  to  a  faulty  condition 
of  the  foot  impairing  its  weight-bearing  strength.  It  may  be  defined 
.technically  as  a  static  pes  plano-valgus. 

The  terms  "  foot  strain,"  "  weak  foot,"  "  pronated  foot,"  etc.,  are 
also  used  to  designate  this  condition,  but  the  whole  terminology  must 
be  regarded  as  unsettled  and  loose.  The 
term  flat-foot  is  employed  here  as  being 
the  one  most  often  used. 

The  human  foot  normally  changes  in 
shape  as  the  superimposed  body  weight  is 
shifted  in  the  different  static  conditions 
incident  to  human  action.  Man  as  a 
hunter  and  fighter  needs  not  only  swift- 
ness of  foot  but  firm  play  and  agility  in 
his-  footing  while  using  his  arms  and 
hands  in  combat.  This  is  secured  by  a 
function  of  the  tarsus,  peculiar  to  man, 
whereby  a  side  play  of  the  midtarsus  is 
possible  while  the  heel  and  front  of  the 
foot  are  firmly  planted  upon  the  ground. 
When  the  body  weight  is  supported 
equally  on  both  feet,  the  weight  falls 
through  the  astragalus  on  the  end  of  the 
os  calcis  and  the  heads  of  the  metatarsals ; 
but  if  the  load  is  shifted  to  either  side, 
the  midtarsus  moves  with  it,  the  limb  ro- 
tating at  the  midtarsal  articulation  at  the 
hip- joint.  The  normal  check  to  too  great 
outward  twist  is  in  the  locking  of  the  midtarsal  bones  as  the  weight 
falls  on  the  outer  edge  of  the  foot,  giving  a  firm  base  of  support,  but 
for  inward  rotation  the  check  lies  in  ligaments  and  muscles. 

When  the  front  of  the  foot  is  turned  out  too  far  or  too  constantly 

381 


FIG.  345. — Print  of  Arab  Foot. 


382 


ORTHOPEDIC  SURGERY 


while  the  midtarsus  is  twisted  in,  a  condition  of  chronic  strain  follows 
which  may  lead  to  ligamentous  irritation,  too  great  inward  play  of  the 
midtarsus,  or  abnormal  position  of  the  tarsal  bones;  in  short,  toward 
pes  plano-valgus  or  flat-foot. 

Up  to  a  certain  limit  this  movement  occurs  in  normal  feet,  but 
beyond  this  what   must  be   regarded   as  a  pathological  condition  is 


. 


FIG.  346. — Casts  of  Civilized  and  of  Savage  Feet. 

reached,  attended  by  symptoms  of  pain  and  disability,  and  is  the  first 
step  in  the  formation  of  flat-foot. 

The  symptoms  of  foot  strain  expressed  as  painful  muscular  liga- 
mentous irritation  may  therefore  exist  in  feet  where  the  relations  of 
the  different  bones  may  appear  to  be  normal,  that  is.  where  no  per- 
ceptible deformity  can  be  seen  to  exist. 

The  deformity,  strictly  speaking,  is  not  a  flattening  of  the  foot, 
but  consists  of  an  exaggerated  midtarsal  drop  and  twist.  The  move- 
ment is  a  combination  of  inward  rolling  and  dropping  to  the  inside 
of  the  middle  of  the  foot.  The  individual  stands  with  the  front  of  the 
foot  turned  out  to  give  a  wider  base  of  support.  The  internal  malleoli 
are  unduly  prominent,  corresponding  to  the  well-known  knock-knee 
deformity.  This  mav  be  termed  a  knock-ankle  deformity. 


PATHOLOGICAL  ANATOMY. 

Alterations  in  the  shape  of  the  bcnes  are  noted  in  severe  cases,  the 
external  malleolus  being  at  times  somewhat  flattened  and  rounded,  but 
the  chief  distortion  in  the  bcnes  occurs  in  the  astragalus,  os  calcis, 


FLAT-FOOT 


383 


scaphoid,  and  cuboid.  In  extreme  cases  the  astragalus  has  dropped 
from  above  to  the  inside  of  the  os  calcis,  the  latter  being  rolled  to  the 
inside  with  a  deviation  of  its  forward  end  to  the  inside.  The  front 
of  the  foot  is  turned  outward,  the  scaphoid  and  cuboid  being  prac- 
tically dislocated.  At  the  outer  side  the  cuboid  may  be  displaced 
upward.  Changes  in  the  direction  of  the  metatarsus  and  of  the  pha- 
langes are  found  and  exostoses  are  at  times  developed. 

There  is  a  loss  of  the  normal  play  of  the  bones  in  the  tarsal  articu- 
lations from  loss  of  elasticity  of  the  ligaments,  and  changes  in  the 
shape  of  the  bones  result  from  ab- 
normal pressure.  The  muscles 
are  changed  in  their  strength,  the 
tibialis  being  weakened  and  the 
peronei  contracted.  The  plantar 
ligaments  are  stretched  and  dis- 
placed, and  those  bearing  strain 
are  thickened. 

Varieties. — As  has  been  al- 
ready mentioned,  talipes  valgus 
resembles  flat-foot,  and  they  are 


FIG.  347. — Composite  Photograph,  Showing 
Excursion  of  Malleolus  and  Arch  with  and 
without  Weight-bearing.  (Dane.) 


FIG.  348. — Composite  Photograph,  Showing 
Lateral  Excursion  of  Lower  Leg  and  Foot 
with  and  without  Weight-bearing.  (Dane.) 


often  classed  together.  For  clinical  reasons  it  is  more  convenient  to 
consider  the  subjects  separately.  The  same  is  also  true  of  congenital 
valgus,  sometimes  called  congenital  flat-foot. 

Causation. — In  general  terms  it  may  be  said  that  the  deformity  is 
caused  by  a  disproportion  between  the  weight  to  be  borne  and  the  mus- 


ORTHOPEDIC  SURGERY 

cular  power  which  bears  it.  Footwear  which  cramps  the  front  of  the 
foot,  faulty  attitudes  in  standing  and  walking,  and  whatever  weakens 
the  muscles  of  the  legs  and  feet  are  the  chief  exciting  causes. 

The  most  common  of  traumatic  causes  is  Pott's  fracture,  in  which 
a   deformity   is   the   result   of   inefficient   treatment   or   of   a   severe 


FIG.   349. — Normal   Motion  of  the  Front  of  the   Foot. 

and  intractable  fracture.    The  deformity  is  also  seen  after  tuberculous 
diseases  and  chronic  arthritis  of  the  ankle. 

Many  of  the  barefooted  races  have  been  considered  flat  footed 


FIG.  350. — Weakened  Foot  without  Breaking  Down  of  Arch. 

simply  because  of  the  strong  development  of  the  muscles  of  the  sole, 
careful  examination,  however,  showing  excellent  arches. 

The  most  common  cause  is  the  weakening  of  the  muscles  of  the 
foot  by  shoes.  Shoes  as  worn  by  the  leisure  class  or  by  the  class  that 
gain  their  livelihood  (as  is  the  rule  in  cities)  by  occupations  which 
require  standing  rather  than  strong  and  vigorous  walking,  compress 


FLAT-FOOT 


385 


the  front  of  the  foot.     This  part  of  the  foot,  from  compression  and 
from   resulting  weakness,  cannot  adapt  itself  as  greater  weight  is 


FIG.  351. — Severe  Double  Flat-foot. 


thrown   upon   the   foot,   and  the  medio-tarsal  twisting  takes   place, 
which  in  the  strong  bare  foot  is  prevented  chiefly  by  the  action  of  the 


FIG.  352  — Displacement  of  Little  Toe.      (H.  L.  Burrell.) 

tibial  muscles  and  by  the  muscles  of  the  first  metatarsal  and  its 
phalanges.  People  the  front  of  whose  feet  have  been  compressed 
stand  and  walk  with  a  greater  angle  of  divergence  cf  the  axes  of  the 
feet,  which  increases  the  danger  cf  the  development  of  the  deformity 


386 


ORTHOPEDIC  SURGERY 


by  bringing  greater  strain  upon  the  inner  side  of  the  foot  and  favoring 
the  inward  rolling  which  frequently  develops  flat-foot.  Flat-foot  is 
not  developed  among  mcccasined  savages  who  use  their  feet  actively 
as  hunters,  using  the  muscles  of  the  front  of  the  foot  freely,  nor 
among  sandal-wearing  monks. 


FIG.   353. — Showing  Shoe  Constriction  of   Front  of   Foot,   with   Normal   Foot   in   Shoe   Before 
and   After   Removal   of  Upper. 

Symptoms — Flat-foot  is  a  deformity  characterized  by  a  flattened 
appearance  of  the  sole  of  the  foot. 

It  can  for  convenience  clinically  be  divided  into  two  groups: 

1.  Flexible  flat-foot,  strained  or  weakened  foot,  where  little  or  no 
structural  changes  have  taken  place. 

2.  Rigid  fiat-foot  or  flat-foot  proper,  in  which  the  distortion  is 


FLAT-FOOT 


387 


permanent,  some  structural  change  in  ligaments  or  bones  having  taken 
place. 

DEFORMITY. — In  the  severer  cases,  instead  of  the  normal  arching 
upward  of  the  inner  border  of  the  foot,  this  border  is  either  less 
arched  than  normal  or  is  in  contact  with  the  ground. 

PAIN. — The  first  symptom  complained  of  is  a  sense  of  discomfort 
in  the  feet  after  standing  or  walking.  This  may  increase  until  pain 
of  greater  or  less  extent  is  present  during  and  following  use  of  the 
feet.  In  the  milder  cases  pain  ceases  when  the  weight  is  removed, 


FIG.  354. — a,  Drawing  of  Normal  Position  of  Bones  of  Foot,  b,  Fashionable  Shoe,  c,  Tracing 
of  Skiagram  of  Foot  in  Shoe,  Indicating  Cramping  and  Downward  Pressure  on  the  First 
Metatarsal. 


but  as  the  condition  becomes  more  advanced  the  pain  not  only  be- 
comes more  severe,  but  continues  after  the  use  of  the  feet  is  stopped, 
and  in  the  severer  cases  persists  during  part  of  the  night.  The  severity 
of  the  pain  may  be  greater  than  is  to  be  expected  from  the  amount 
of  distortion;  and,  again,  there  may  be  little  disability,  although  the  de- 
formity is  marked.  The  pain  is  most  frequent  in  the  neighborhood  of 
the  scaphoid;  it  occurs  also  in  front  of  the  foot,  in  the  centre  of  the 
heel,  behind  the  inner  malleolus,  and  on  the  outer  border  of  the  foot. 
Pain  is  also  complained  of  in  connection  with  flat-foot  in  certain  cases 
in  the  leg,  knee,  back,  or  hip. 

TENDERNESS. — Tenderness  may  be  present  over  points  of  liga- 
mentous  strain. 

MUSCULAR  SPASM. — In  very  acute  cases  there  may  be  irritability 
and  contraction  of  the  peroneal  muscles  holding  the  foot  in  the  position 
of  abduction;  in  this  case  there  is  apt  to  be  tenderness  over  the  origin 
of  the  peroneal  muscles. 


388  ORTHOPEDIC  SURGERY 

STIFFNESS. — Congestion  of  the  foot  and  swelling  of  the  foot  and 
leg  are  frequent  symptoms.  Stiffness  or  loss  of  flexibility  is  a  symp- 
tom which  is  gradually  developed,  and  it  involves  at  first  and  most 
prominently  the  medio-tarsal  joint.  The  stiffness  is  such  that  the 
front  of  the  foot  cannot  be  adducted  actively  or  passively  as  much 
as  it  normally  should  be.  This  is  an  important  matter  to  recognize, 
as  it  prevents  an  assumption  of  a  correct  position  by  voluntary  mus- 
cular effort  until  the  proper  flexibility  is  restored.  There  is  also, 
especially  in  the  later  history  of  the  case,  some  limitation  in  the 
plantar  and  dorsal  flexion  of  the  foot  at  the  ankle-joint. 

GAIT. — The  gait  becomes  modified  as  the  affection  progresses  and 
becomes  in  a  measure  characteristic.  The  feet  are  generally  more 
everted  than  normal,  and  in  painful  cases  it  will  be  noted  that  in 
standing  the  patient  deliberately  throws  the  foot  over,  so  that  the 
weight  is  borne  m:  re  upon  the  inner  border  than  is  normal.  The 
front  of  the  foot  is  turned  out  while  the  knee  is  turned  in. 
There  is  a  lack  of  elasticity  to  the  gait,  and  this  is  a  symptom  often 
complained  of  by  the  more  intelligent  patients,  who  find  their  feet 
stiff  and  clumsy.  After  the  patient  has  been  sitting  for  some  time 
and  on  rising  in  the  morning  the  feet  are  likely  to  be  stiff  and 
clumsy. 

Diagnosis. — For  examination  of  the  feet,  the  shoes  and  stockings 
should  be  removed  and  the  patient  should  stand  facing  the  surgeon 
upon  the  floor.  The  patient's  gait  should  be  carefully  watched. 

The  relation  of  the  foot  to  the  leg  should  be  noted,  whether  the 
internal  malleolus  is  unduly  prominent  and  the  foot  rolled  over  on  to 
its  inner  border.  The  height  of  the  arch  of  the  foot  is  of  importance, 
and  any  lowering  of  the  inner  border  is  significant.  The  rolling  of  the 
foot  further  on  to  its  inner  side  or  the  lowering  of  the  arch  after  the 
patient  has  stood  for  a  minute  indicates  muscular  insufficiency  under 
weight-bearing. 

The  imprint  of  the  weight-bearing  foot  is  of  interest.  This  is 
taken  by  having  the  patient  step  on  a  piece  of  cardboard  blackened 
with  camphor  smoke  ;  the  non-weight-bearing  position  of  the  foot  is  re- 
corded first  and  then  the  weight-bearing  position,  the  two  being  super- 
imposed in  the  completed  tracing. 

The  degree  of  flexibility  should  be  examined  by  attempting  to  ad- 
duct  the  forefoot  gently  with  the  hands  and  to  flex  the  foot  dorsally 
with  the  patient's  knee  extended.  Loss  of  the  first  of  these  move- 
ments is  of  diagnostic  importance. 

The  presence  of  tender  points  in  the  sole  of  the  foot,  either  under 


FLAT-FOOT  389 

the  heel  or  under  the  scaphoid,  generally  indicates  static  disturbance 
of  the  foot.  The  occasional  assumption  of  the  plano-valgus  position 
does  not  constitute  flat-foot.  The  deformity  is  a  constant  faulty  atti- 
tude and  the  inability  to  bear  the  body  weight  without  discomfort. 

An  .r-ray  examination  is  of  assistance  in  determining  any  dis- 
placement in  the  relation  of  the  bones  to  each  other  occurring  in  the 
severer  grades  of  the  affection  and  not  present  in  the  lighter  grades. 
It  is  also  of  value  in  giving  information  as  to  the  presence  of  arthritis 
deformans  and  the  existence  of  exostcses. 


^••^^^•••••^^•^••^•i 

FIG.  355. — Tracing  of  a  "  Flat-foot."      No  symptoms. 


Prognosis. — After  a  time  the  foot  may  become  accustomed  to  its 
altered  position  and  painful  symptoms  cease.  In  other  cases,  how- 
•ever.  the  painful  symptoms  continue  and  become  worse  rather  than 
better. 

The  condition  may  persist  almost  indefinitely,  a  constant  source  of 

pain  and  disability. 

Treatment. — Treatment  of  the  conditions  described  should  be  di- 
rected to  the  replacement  of  displaced  tarsal  bones,  relief  of  strains, 
overcoming  midtarsal  stiffness  and  restoration  of  the  muscular 
strength  needed  in  sustaining  the  body  weight. 


390 


ORTHOPEDIC  SURGERY 


The  latter,  in  lighter  cases,  can  be  secured  by  the  exercise  of  the 
feet  untrammelled  by  foot-cramping  shoes — moccasin  walking  on  turf, 
snowshoeing,  or  flexible  shoe  activity  on  uneven  surfaces. 

The  goose-step  gymnastics  and  marching  in  army  shoes  give  foot 
strength  to  recruits,  and  the  same  can  be  done  in  civil  life;  but  care- 


FIG.   356. — a,  Photograph   of  Humped  Foot,      b,  Tracing  of   Skiagram  of  Humped  Foot  with 
Irritation   Exostosis  of  the   Metatarso-cuneiform  Articulation. 

ful  directions  as  to  daily  foot  exercises,  the  proper  use  of  shoes,  and 
correct  attitudes  in  standing  and  walking  are  usually  needed. 

Various  exercises  can  be  employed.  The  following  simple  ones 
will  be  found  of  service  to  increase  midtarsal  flexibility  and  foot  mus- 
cular strength. 

1.  The  patient,  sitting  forward  on  a  chair,  with  the  feet  crossed, 
and  resting  on  their  outer  edges,  alternately  partially  rises  and  sits. 

2.  The  patient,  standing,  with  one  foot  in  front  of  the  other,  the 
front  foot  turned  in,  and  the  rear  foot  resting  behind  the  front  leg  on 
its  outer  edge,  lowers  himself  a  number  of  times  by  bending  his  knee, 
without  changing  the  position  of  his  feet. 

3.  The  patient   walks  with  the   front   of   the    feet  strongly  ad- 
ducted. 


FLAT-FOOT  39i 

4.  The  patient,  standing  with  the  feet  closely  touching,  bends  the 
knees  as  far  as  possible  without  raising  the  heels  from  the  floor,  and 
then  spreads  the  knees,  keeping  the  soles  of  the  feet  flat. 

5.  The  patient  places  his  foot  with  the  leg  of  a  light  chair  between 
the  first  and  second  toe,  throws  his  weight  on  the  ball  of  the  foot, 
bends  the  knee  and  turns  the  limb  outward,  keeping  the  sole  and  heel 
flat. 


FIG.  357. — Deformity  Caused  by  the  Constriction  and  Confinement  of  the  Foot. 

6.  The  patient  sits  with  the  affected  ankle  resting  on  the  knee  of 
the  other  limb,  the  inner  edge  of  the  foot  directed  upward ;  a  weight 
connected  to  a  strap  is  hung  over  the  front  of  the  foot,  which  is  raised 
without  raising  the  leg. 

7.  The  patient  sitting  with  the  legs  crossed  presses  down  with 
the  hand  upon  the  inner  front  border  of  the  foot  and  attempts  to 
adduct  the  front  of  the  foot  by  raising  it  against  the  pressure  of  the 
hand. 

8.  The  patient,  curling  the  toes  over  the  round  of  a  chair,  drags 
the  chair,  which  can  be  made  heavy  if  loaded  with  weights. 

In  addition  to  this,  rolling  heavy  dumb-bells  with  the  feet,  exer- 
cises in  picking  up  small  rubber  balls,  weight  and  pulley  exercises  with 
straps  attached  to  the  front  of  the  foot  can  serve  to  strengthen  the  feet 
and  whole  limb. 


392 


ORTHOPEDIC  SURGERY 


FIG.  358. — Apparatus  for  Increasing  Adduction 
of   Front  of   Foot. 


In  resistant  cases  it  is  necessary  to  correct  midtarsal  stiffness  by 
mechanical  means.  This  can  be  done  by  a  simple  appliance.  The 
front  of  the  foot  is  strapped  on  to  a  board,  a  peg  is  placed  between 

the  first  and  second  toes,  and  a 
small  block  against  the  outer  side 
of  the  heel.  A  rod.  used  as  a 
lever  placed  against  the  inner  side 
of  the  foot  and  under  the  head 
of  the  astragalus  is  made  to  press 
this  portion  of  the  foot  out- 
ward. 

Patients  should  be  trained  in 
standing  and  walking  so  that 
faulty  position  should  not  be 
habitual,  i.e.,  those  in  which  the 
weight  falls  more  upon  the 
weaker  or  inner  than  on  the  outer, 
stronger  foot  arch.  They  should 
not  stand  with  the  feet  turned 
out  and  the  limb  turned  in, 
or  walk  with  the  front  of  the 
foot  abducted  and  not  adducted. 
This  latter,  common  in  the 
weak-limbed,  is  easily  recog- 
nized if  the  gait  is  watched,  and 
by  determining  the  axis  of  the 
patella. 

Supports. — When  the  foot  is 
overweighted  and  too  much  strain 
put  on  the  inner  arch,  relief  is 
furnished  if  a  firm  support  is 
placed  underneath  the  part  of  the 
foot.  This  can  be  furnished  by 
means  of  a  thin  steel  plate  of  a 
suitable  shape  placed  in  the  shoe 
and  made  from  a  plaster  cast  of 
the  foot.  The  latter  should  be 
carefully  made.  The  patient's 
foot  should  first  be  encased  in 

several    layers   of   cheesecloth    heavily    loaded   with    plaster-of-Paris 
cream.    While  this  is  hardening,  the  foot  is  placed  upon  the  floor  with 


FIG.  359. — Apparatus    for    Exercising    Foot    in 
Flat-foot. 


FLAT-FOOT 


393 


the  arch  in  the  best  possible  position.     When  this  has  hardened  it  is 
cut  off  the  foot  and  serves  as  a  mould  for  the  cast. 

Another  method  of  preparing  casts  for  plates  is  to  model  them 
from  moulds  of  the  foot  made  in  dental  wax.  If  a  sheet  of  quickly 
hardening  dental  wax  is  softened  in  hot  water  and  placed  upon  the 
bottom  of  the  foot,  a  mould  can  be  taken.  When  it  is  hardened  it  can 


FIG.   ,juu. — Flat-foot   Plates. 


FIG.  361. — Flat-foot  Plate 
Raised  in  Front  to  Support 
Anterior  Arch. 


be  removed  from  the  foot,  and  can  be  cut  and  moulded  to  any  desired 
shape  by  immersion  again  in  hot  water.  In  this  way  a  wax  flat-foot 
plate  is  made  fitted  to  the  boot.  A  plaster-of-Paris  cast  can  be  taken 
of  this,  and  reproduces  exactly  the  shape  and  size  of  the  plate  desired. 

Manufacture  and  Material. — The  best  all-round  material  for  the 
manufacture  of  plates  is  a  spring  tempered  steel  of  a  gauge  varying 
from  eighteen  to  twenty,  according  to  the  weight  of  the  patient.  For 
the  manufacture  of  plates  from  this  material,  the  services  of  an  instru- 
ment-maker or  of  a  skilful  blacksmith  are  necessary.  The  cast  should 
.be  furnished  to  him  and  the  plate  forged  to  fit  the  cast  exactly.  It 
should  then  be  tried  on  the  patient,  before  or  after  which  it  should 
be  tempered.  For  final  use  the  plate  should  be  copper-plated  and 
nickel-plated. 

By  another  method  the  surgeon  is  able  to  manufacture  the  sup- 
port himself.  A  celluloid  paste  is  made  by  dissolving  celluloid  chips 
in  acetone ;  this  is  then  painted  on  to  several  layers  of  gauze  laid  on 
the  cast,  between  which  strips  pieces  of  steel  wire  are  incorporated. 
The  wires  are  laid  on  in  different  directions,  giving  strength  as  de- 


394  ORTHOPEDIC  SURGERY 

sired.  When  the  celluloid  has  hardened,  the  edges  of  the  plate  should 
be  trimmed. 

Shape  of  Plates. — Judgment  is  necessary  in  determining  the  proper 
shape  of  the  plate  in  each  case,  as  the  deformity  varies  both  in  degree 
and  in  kind.  The  shape  should  be  determined  by  the  part  of  the 
foot  which  needs  corrective  support.  As  a  rule,  the  scaphoid  and 
proximal  end  of  the  first  metatarsal  and  the  sustentaculum  tali  need 
to  be  raised.  In  some  cases  the  tendency  of  the  os  calcis  to  rotate  to 
the  inner  side  of  the  foot  is  to  be  checked,  and  in  other  cases  side 
pressure  is  needed  on  the  head  of  the  astragalus,  scaphoid,  and  cunei- 
form, with  counter-pressure  on  the  outer  side  of  the  foot.  The  most 
practical  way  of  determining  what  shape  of  plate  is  desirable  is  to 
have  the  patient  stand,  and  by  pressure  with  the  hand  to  see  in  what 
place  the  force  accomplishes  the  best  result.  In  general,  a  plate  should 
be  higher  along  the  inner  part  of  its  surface  than  on  the  outer,  but  it 
should  not  be  made  so  sloping  that  the  foot  continually  slides  off.  If 
this  is  the  case  a  counter-point  of  pressure  may  be  furnished  by  turn- 
ing up  the  outer  flange  at  the  outer  edge  of  the  plate.  Ordinarily  it 
is  advisable  to  have  the  plate  support  nearly  the  whole  width  of  the 
sole,  ending  in  front  behind  the  sesamoid  bones  of  the  great  toe  and 
at  the  back  end  just  anterior  to  the  weight-bearing  surface  of  the 
heel,  or,  if  desired,  running  to  the  back  of  the  weight-bearing  surface 
of  the  heel. 

If  the  anterior  part  of  the  foot  is  broken  down,  support  to  it 
should  be  furnished  by  raising  the  front  of  the  plate  in  a  dome-shaped 
rise,  supporting  the  part  of  the  foot  behind  the  heads  of  the  meta- 
tarsals.  In  flexible  feet  a  shorter  plate  can  be  used  than  in  rigid  feet. 
The  need  of  an  inner  flange  and  its  height  will  be  determined  by  the 
requirements  of  the  case ;  the  same  is  true  of  the  outer  flange.  The 
plate  at  its  outer  border  should  not  project  beyond  the  outer  edge  of 
the  shank  of  the  boot,  or  it  will  push  out  the  leather  and  destroy  the 
shape  of  the  boot. 

Fitting  and  Use. — The  plate  should  be  shaped  in  such  a  way  as  to 
act  as  a  prop  to  the  portions  of  the  feet  which  drop  to  an  abnormal 
position  when  weight  is  thrown  upon  them.  In  the  practical  fitting  of 
the  plate,  if  the  plate  is  rightly  shaped,  the  foot  when  not  bearing 
weight  should  lie  smoothly  against  the  bottom  of  the  plate,  not  spring- 
ing off  at  the  front  or  back.  If  it  springs  off.  it  will  exert  more 
pressure  than  is  generally  comfortable.  When  the  plate  is  placed  in 
the  boot  and  the  patient  stands  upon  it,  there  should  be  a  sense  of  even, 
well-distributed  pressure,  and  not  a  feeling  as  if  the  patient  were 


FLAT-FOOT  395 

standing  on  a  ridge  or  lump,  which  will  be  the  case  if  the  plate  is  too 
high.  If  an  inner  flange  is  used  it  should  not  press  too  much  upon 
the  foot  when  weight  is  borne  upon  it.  If  sensitive  points  in  the  foot 
are  present  and  cause  pain  when  weight  is  borne  upon  the  plate,  it  will 
be  necessary  to  lower  the  plate  opposite  these  points.  When  the  plate 
is  first  applied  it  should  be  worn  only  for  so  long  a  period  as  is  con- 
sistent with  the  comfort  of  the  patient,  and  should  then  be  taken  out 
to  rest  the  foot  if  necessary.  If  the  plate  is  persistently  a  source  of 
pain  it  will  not  give  the  desired  relief,  but  will  cause  irritation  and 
must  be  lowered  until  it  is  comfortable.  No  point  is  more  commonly 
neglected  than  this,  and  the  very  common  use  by  patients  of  ill-fitting 
supports  bought  at  shoe-stores  brings  much  discredit  upon  the  use  of 
plates.  The  plate  should  set  firmly  in  the  shoe  and  should  not  rock, 
and  the  front  and  back  ends  should  be  in  contact  with  "the  sole  of  the 
boot. 

Misuse  of  Plates. — The  danger  of  injury  to  the  feet  by  the  too 
constant  use  of  plates  is  to  be  borne  in  mind.  The  plate  is  to  be  re- 
garded in  the  same  light  as  is  a  crutch  or  cane  in  the  case  of  any  joint 
unable  to  bear  the  strain  of  use,  and  is  to  be  discarded  when  the  normal 
strength  has  returned  and  the  irritability  has  disappeared.  To  con- 
tinue the  plate  after  the  indications  for  its  use  have  disappeared  is  to 
hamper  the  muscles  of  the  feet  and  to  prolong  the  unnatural  condition. 

Pads. — The  use  of  felt  or  leather  pads  supporting  the  arch  of  the 
foot  is  sometimes  of  use  temporarily  or  under  exceptional  conditions. 
Such  pads  may  be  cut  of  the  desired  shape  and  worn  outside  the  stock- 
ing by  being  fastened  to  an  inner  sole  of  leather.  If  they  are  worn 
for  any  length  of  time  the  weight  of  the  foot  stretches  the  leather  of 
the  boot  and  breaks  down  the  shank  and  they  cease  to  be  of  value. 

The  Oblique  Sole. — Palliative  treatment  is  often  attempted  in 
cases  of  flat-foot  by  making  the  inner  side  of  the  sole  and  heel  of  the 
boot  one-eighth  or  one-fourth  of  an  inch  thicker  than  the  outside. 
The  weight  is  in  this  way  thrown  more  to  the  outer  side  of  the  foot 
and  the  strain  on  the  inner  side  is  somewhat  relieved.  The  thickness 
of  the  wedge  which  is  necessary  may  be  determined  experimentally 
by  building  up  the  inner  side  of  the  boot  till  the  desired  position  is 
obtained,  as  determined  by  the  diminution  in  the  projection  of  the 
internal  malleolus. 

It  is  to  be  remembered  that  in  the  correction  of  flat-foot  not 
only  should  the  body  weight  fall  well  on  the  outer  edge  of  the  foot, 
but  the  great  toe  and  head  of  the  first  metatarsal  should  perform  their 
normal  functions  in  locomotion. 


396  ORTHOPEDIC  SURGERY 

MASSAGE,  GYMNASTICS,  ETC. — The  supportive  treatment  of  flat- 
foot  should  be  reinforced  by  measures  to  stimulate  the  local  circula- 
tion and  to  strengthen  the  muscles  of  the  foot.  Massage  is  of  the  first 
importance,  but  should  not  be  pushed  to  the  point  of  irritation.  The 
use  cf  alternating  hot  and  cold  douches  or  of  a  local  hot  bath  followed 
by  a  cold  douche  is  of  much  value.  Vibratory  massage,  electricity, 
and  the  use  of  hot  air  may  be  of  use  in  especial  cases. 

As  barefooted  and  sandal-wearing  people  are  free  from 
pes  plano-valgns,  the  footwear  should  constrict  the  front  of  the 
foot  and  limit  free  action  of  the  muscles  of  the  foot  as  little  as 
possible. 

Moccasins  and  sandals  should  be  worn  when  practicable,  but  it  is, 
however,  evident  that  feet  weakened  by  constant  confinement  in  stiff 
boots  must  be  gradually  strengthened  before  continued  free  action  is 
possible  without  some  discomfort. 

The  shape  of  the  shoe  has  become  conventionalized  to  such  an 
extent  that  the  general  use,  among  the  leisure  class,  of  shoes  of  the 
shape  of  the  normal  foot  is  not  practicable.  The  people  of  the  city 
streets  will  not  be  shod  as  hunters.  It  is,  however,  practicable  to  limit 
the  use  of  fashionable  shoes  for  leisure  hours  and  to  furnish  working 
boots  for  working  hours.  The  boots  should  be  adapted  to  the  gait 
and  use.  People  who  use  the  front  of  the  feet  in  locomotion,  "  front- 
foot  "  walkers,  and  those  walking  on  uneven  ground  need  more  room 
in  the  front  of  their  boots  than  heel  walkers  or  those  who  walk  on 
an  even  surface. 

THE  TREATMENT  OF  PAINFUL  CASES. — In  certain  cases  the  symp- 
toms of  local  irritability  reach  so  high  a  grade  that  especial  treat- 
ment is  needed.  Spasm  of  the  peroneal  muscles  may  be  present, 
holding  the  foot  in  an  abducted  position  and  resisting  movements  of 
rectification.  In  this  case  temporary  fixation  of  the  foot  in  a  plaster 
bandage  is  the  most  efficient  measure,  or  the  use  of  adhesive  plaster 
strapping,  as  in  sprained  ankle. 

Forcible  Correction. — In  cases  in  which  it  is  not  possible  to  place 
the  foot  in  an  approximately  correct  position  on  account  of  stiffness 
and  muscular  contraction,  it  is  generally  unsatisfactory  to  attempt 
the  use  of  a  support  until  the  position  of  the  foot  has  been  corrected. 
Such  patients  should  be  anaesthetized  and  the  foot  forcibly  twisted 
into  shape.  It  must  be  remembered  that  there  are  two  elements  of 
deformity  to  be  corrected :  first,  eversion  of  the  foot ;  and,  second, 
abduction  of  the  forefoot.  This  can  be  done  manually  in  many  cases, 
but  in  severe  cases  such  an  appliance  as  the  Thomas  club-foot  wrench 


FLAT-FOOT 


397 


or  the  one  shown  in  the  illustration  will  be  of  use  in  giving  better 

leverage,  or  the  foot  can  be  manipulated  over  a  padded  wooden  wedge. 

The  foot  should  be  overcorrected  if  possible,  or  in  any  event 

placed  in  the  best  obtainable  position  and  held  by  a  plaster  bandage. 


FIG.  362.— Forcible  Correction  of  Valgus  on  Wooden  Block.      (Berger  and  Banzet.) 

It  then  follows  the  course  of  an  ordinary  sprained  ankle,  generally 
of  slight  degree.  As  soon  as  the  patient  can  walk  without  pain,  sup- 
ports should  be  applied. 


FIG.   363. — Apparatus  for  Forcible  Correction  of  Rigid   Flat-foot. 

In  less  severe  cases,  correction  can  be  gradually  accomplished  by 
the  repeated  application  of  plaster-of -Paris  bandages  without  an- 
aesthesia. 

In  extreme  cases  osteotomy  of  the  neck  of  the  os  calcis  and  as- 
tragalus may  be  needed,  or  the  removal  of  a  wedge-shaped  piece  of 


398  ORTHOPEDIC  SURGERY 

bone  from  the  inner  side  of  the  neck  of  the  astragalus  undertaken;  but 
in  a  majority  of  cases,  even  the  severe  ones,  forcible  correction  will 
be  found  more  efficient  than  wedge-shaped  resection,  as  the  distortion 
will  be  found  to  be  distributed  in  various  parts  of  the  foot,  and  ex- 
tensive removal  of  bone  will  be  followed  by  weakening  of  the  foot. 
The  correction  of  the  complicating  deformity  of  hallux  valgus  is  often 
necessary  for  the  cure  of  flat-foot. 


CHAPTER  XX. 

METATARSALGIA  AND  OTHER  DEFORMITIES  OF  THE 

FOOT. 

METATARSALGIA. 

THE  name  metatarsalgia  or  anterior  metatarsalgia  is  used  to  de- 
scribe a  pain  more  or  less  spasmodic,  situated  at  the  distal  end  of  either 
of  the  outer  three  metatarsal  bones. 

Causation. — The  pain  is  due  to  a  disturbance  in  the  normal  rela- 
tion of  the  anterior  ends  of  the  metatarsal  bones,  causing  a  pinching 
of  the  external  plantar  nerve  between  the  ends  of  the  bones,  to  pres- 
sure of  the  metatarsals  on  other  digital  nerves,  to  abnormal  strain 
upon  the  ligaments  connecting  the  metatarsal  heads,  or  to  a  bruise  of 
the  tissues  by  these  bones. 

The  affection  is  thus  due  to  the  disturbed  relation  in  the  position 
of  the  metatarsals  caused  by  faulty  footwear.  Normally  the  head  of 
the  first  metatarsal  bears  a  large  part  of  the  weight  which  comes  upon 
the  front  of  the  foot.  If  footwear  is  worn  which  gives  insufficient 
room  for  the  toes  and  at  the  same  time  exerts  a  crowding  pressure 
upon  the  metatarsals,  the  heads  of  the  first  and  fifth  metatarsals  are 
unable  to  drop  to  the  normal  plane  below  the  level  of  the  other  meta- 
tarsals, owing  to  the  narrowness  of  the  shoe.  The  weight  therefore 
falls  unduly  on  the  heads  of  the  other  metatarsals,  which  are  crowded 
downward  as  the  foot  slips  forward  in  the  boot. 

Symptoms. — The  condition  is  characterized  by  a  more  or  less  se- 
vere pain,  which  radiates  down  into  the  toes  and  often  up  into  the 
leg.  It  occurs  generally  between  the  third  and  fourth  or  fourth  and 
fifth  toes.  It  may  be  preceded  by  a  sensation  of  slipping  between  the 
ends  of  the  metatarsals,  or  the  slipping  may  occur  without  the  pain. 
It  ordinarily  comes  on  when  the  boots  are  on,  but  may  sometimes  be 
occasioned  by  rising  on  the  toes  in  the  stocking  feet.  The  patient 
seeks  relief  instinctively  by  removing  the  boot  and  manipulating  the 
foot,  which  relieves  the  acute  pain.  Some  soreness  may  remain  after- 
ward and  a  tender  spot  is  often  found  at  the  seat  of  the  pain. 

The  attacks  of  pain  may  become  gradually  more  frequent  and 

399 


400 


ORTHOPEDIC  SURGERY 


more  severe  until  a  condition  of  disability  is  established,  the  patient 
dreading  walking. 

The  foot  may  be  normal,  so  far  as  can  be  ascertained  on  inspec- 
tion, but  on  palpation  the  heads  of  the  second,  third,  or  fourth  meta- 
tarsals  will  be  found  habitually  on  a  lower  plane  than  normal,  and 
callosities  may  be  found  under  the  heads  of  the  metatarsals. 

Diagnosis. — This  affection  is  frequently  diagnosticated  as  neu- 
ralgia, for  which  only  general  treatment  is  prescribed,  yet  the  diag- 
nostic symptoms  are  perfectly  well  marked  and  definite  and  not  like 
those  of  any  other  affection. 

The  prognosis  without  treatment  is  not  good ;  the  attacks  as  a  rule 
become  more  frequent  and  painful,  though  spontaneous  recovery  does 
rarely  occur.  \Yith  proper  mechanical  treatment  most  patients  re- 
cover, but  occasionally  very  obstinate  cases  are  seen  which  resist  all 
the  ordinary  methods  of  treatment. 

Treatment. — Measures  should  be  adopted  to  relieve  the  front  ends 
of  the  metatarsals  from  pressing  down  on  to  the  sole  of  the  foot  in 
finishing  the  step  in  walking. 

Proper  boots  with  a  sole  broad  at  the  toes  and 
under  the  tread  of  the  foot,  but  holding  the  foot 
firmly  around  the  midtarsus,  should  be  worn. 
High-heeled  shoes  and  shoes  with  a  cross  welt 
pressing  the  metatarsals  down  to  the  sole  should 
be  avoided.  The  normal  flexibility  of  the  toes 
should  be  developed  by  proper  exercises.  In  some 
cases,  compression  of  the  shafts  of  the  metatarsals 
for  a  time  affords  relief.  In  these  cases  it  can  be 
afforded  by  adhesive  plaster,  by  bandaging,  or  by 
a  soft  leather  strap.  Removal  of  the  distal  end 
of  the  fourth  metatarsal  has  been  advocated  as  a 
measure  of  treatment,  but  it  is  not  often  necessary 

FIG.  364. — Meyer's  Line  ,  -        . .     - 

in  Average  Foot.          and  not  a  means  of  relief. 

CONTRACTED   FOOT. 

A  condition  described  originally  by  Shaffer  as  "non-deforming  club- 
foot  "  and  recently  spoken  of  as  ''  the  muscle-bound  foot  "  consists  in 
a  loss  of  the  dorsal  flexion  of  the  foot,  whereas,  normally,  this  motion 
should  exist  to  15  or  20  degrees  beyond  a  right  angle  when  the  knee 
is  extended.  In  the  condition  described  it  is  limited  at  a  right  angle 
or  less.  The  etiology  is  obscure,  but  the  symptoms  consist  in  cramps 
in  the  calves  of  the  legs,  a  slight  loss  of  lightness  in  walking,  and  per- 


UBFCFY  OF 
HALLUX  VALGU£r'LI-I 


.,          -     . 
haps  backache;  such  patients  tire  easily  in  walking  and  standing.     The 

foot  appears  highly  arched  and  in  weight-bearing  pronates  less  than 
normal.  The  tissues  of  the  sole  are  therefore  subject  to  constant  irri- 
tation in  walking. 

Relief  can  generally  be  afforded  by  supporting  the  arch  of  the  foot 
by  flexible  pads  and  temporarily  raising  the  heel  to  take  the  strain  off 
of  the  irritated  calf  muscles.  Division  of  the  tendo  Achillis  is  only 
required  in  severe  cases. 

HALLUX   VALGUS. 

This  name  is  applied  to  the  outward  displacement  of  the  great  toe. 
In  the  normal  foot,  as  seen  in  children  and  people  who  do  not  wear 

boots,  the  long  axis  of  the  great  toe 
when  prolonged  backward  passes 
through  the  centre  of  the  heel 
(Meyer's  line). 

Causation. — This  deformity  of 
the  great  toe,  however,  is  not  neces- 
sarily the  result  of  tight  shoes,  for 


FIG.  365. — Hallux  Valgus.     Great  toe  under. 


FIG.  366.— Hallux  Valgus.     Great  toe  over. 


the  deformity  may  come  in  people  who  have  worn  only  comparatively 
loose  ones.  The  upper  leather  of  shoes,  being  more  yielding  than 
the  sole,  stretches  under  the  pressure  of  use,  or  is  stretched  to  avoid 
pressure  upon  the  metatarso-phalangeal  articulation.  The  boot  is  not 


402  ORTHOPEDIC  SURGERY 

stretched  at  its  extreme  end  and  it  inevitably  becomes,  in  a  degree, 
conical  in  shape  on  this  account,  being  broader  across  the  ball  of  the 
foot  than  at  the  tip  end.  In  the  act  of  walking  the  foot  necessarily 
slips  inside  of  the  boot  to  a  certain  extent,  and  if  the  shoe  slips  back- 
ward and  the  foot  forward,  a  certain  amount  of  pressure  will  come 
upon  the  inner  side  of  the  end  of  the  great  toe,  tending  to  displace  it 
outward. 

This  deformity  may  also  be  occasioned  by  short  boots,  and  the 
ordinary  pointed-toe  boots,  or  any  boot  which  does  not  give  more 
room  for  lateral  spreading  at  the  toes  than  at  the  metatarso-phalangeal 
articulation,  would  necessarily  give  rise  to  the  trouble.  Stockings 
may  be  also  a  factor  in  its  production.  The  deformity  is  also  favored 
by  walking  with  too  great  abduction  of  the  front  of  the  foot. 

Symptoms. — When  the  deformity  continues  for  any  length  of  time, 
alteration  in  the  relation  of  the  bones  of  the  metatarso-phalangeal 
joint  takes  place.  An  exaggerated  adduction  of  the  first  metatarsal 
with  an  abduction  of  the  phalanx,  and  the  head  of  the  metatarsal  may 
become  enlarged  from  growth  of  the  bone  due  to  periosteal  irritation. 
The  skin  over  this  prominent  joint  often  grows  thick  and  a  bursa  forms 
over  it.  This  may  become  inflamed  and  may  give  rise  to  an  extensive 
cellulitis,  which  at  times  includes  the  whole  dcrsum  of  the  foct;  this 
may  suppurate  and  cause  necrosis  of  the  bcne.  This  latter  termination 
is,  however,  rare  and  occurs  only  in  neglected  cases.  The  inflammation 
of  this  bursa  is  known  as  a  bunion.  Associated  with  a  hallux  valgus 
deformity,  an  exaggerated  inward  divergence  of  the  first  metatarsal  is 
sometimes  seen.  On  examination,  sensitiveness  of  the  metatarso- 
phalangeal  joint  is  detected  on  pressure.  In  its  more  marked  degree 
it  is  almost  exclusively  an  affection  of  adult  life. 

Treatment. — The  treatment  of  hallux  valgus  in  early  cases  may  be 
carried  out  by  wearing  a  splint  of  steel  or  hard  rubber  along  the  inner 
border  of  the  foot  fastened  behind  to  the  metatarsus.  To  the  front 
end  of  this  splint  the  toe  is  bandaged  or  strapped  and  thus  pulled 
inward.  This  can  be  worn  at  night  and  a  "  toe  post  "  in  the  day- 
time. This  consists  of  a  stiff  partition  (of  leather  or  stiff  felt)  con- 
nected to  an  inner  sole  of  the  shoe  and  arranged  so  as  to  press  the 
great  toe  to  the  inside.  A  stocking  divided  so  as  to  allow  separation 
of  the  great  toe  from  the  others  is  also  advisable.  Broad-toed  shoes 
are  essential. 

Operation. — In  old  cases  attempts  to  correct  the  deformity  by  such 
means  as  these  mentioned  are  generally  unsuccessful  and  operative 
measures  may  be  adopted.  The  usual  operation  for  this  deformity  is 


HALLUX   VARUS  403 

the  removal  of  a  wedge-shaped  piece  of  bone  from  the  inner  side  of 
the  head  of  the  first  metatarsal,  close  to  the  joint,  without  opening 
the  joint,  followed  by  forcible  straightening  of  the  phalanx. 

For  the  best  ultimate  result  it  is  desirable  to  avoid  removing  much 
of  the  head  of  the  first  metatarsal,  which  is  important  in  the  weight- 
bearing  function  of  the  foot,  and  in  some  cases  a  linear  osteotomy  on 
the  outer  side  of  the  head  of  the  first  metatarsal,  followed  by  forcing 
the  toe  inwards,  furnishes  a  more  serviceable  foot,  especially  if  the 


FIG.  367.— Hallux  Valgus  or  Out-toe. 


attachment  of  the  extensor  proprius  pollicis  be  shifted  so  as  to  pull 
the  toe  to  the  inside. 

The  use  of  properly  made  shoes  is  essential  for  after-treatment, 
and  also  for  the  prevention  of  the  increase  or  recurrence  of  the  de- 
formity. 


HALLUX  VARUS. 


This  deformity  is  not  a  common  one,  and  is  known  also  as  in-toe 
or  pigeon-toe.  It  is  occasionally  seen  in  barefooted  people,  and  has 
been  observed  in  the  Filipinos.  This  distortion  does  not  generally 
require  treatment,  and  the  use  of  ordinary  shoes  is  sufficient  to  correct 
the  deformity. 


404  ORTHOPEDIC  SURGERY 

HALLUX   RIGIDUS. 

This  deformity,  a  stiffness  of  the  metatarso-phalangeal  joint  of 
the  great  toe,  is  sometimes  seen  in  adolescents  and  adults. 

The  symptoms  vary  with  the  stage  of  the  disease.  Early  there 
may  be  slight  pain  over  the  joint  and  painful  motion,  but  the  cases 
rarely  come  to  the  surgeon's  notice  at  this  time.  Later  there  is  swell- 
ing over  the  joint,  with  tenderness,  and  perhaps  an  enlargement  of 
the  bone  itself. 

The  treatment  in  the  early  stages  will  consist  in  removing  the 
exciting  cause.  If  there  is  pain,  with  signs  of  inflammation,  rest  with 
local  applications  is  indicated.  A  boot  with  a  stiff  rocker  sole  or  with 
an  elevation  raising  the  ball  of  the  foot  and  clearing  the  toe  from 
striking  the  ground  in  walking  may  be  temporarily  needed.  Operative 
measures  to  give  motion  to  the  joint,  forcible  bending,  or  cutting  down 
on  the  joint  freeing  adhesions,  and  the  insertion  of  flaps  of  fat  tissue 
or  Cargile  membrane  might  be  considered,  but  will  be  rarely  needed. 

HAMMER   TOE. 

This  deformity  consists  of  a  claw-like  contraction  of  one  of  the 
toes,  usually  the  second  or  third.  The  condition  is  one  of  flexion  of 
the  second  phalanx,  with  extension  of  the  third,  so  that  the  pressure 
on  the  ground  is  sustained  by  the  disfal  phalanx.  Over  the  upward 
projecting  joint  there  is  usually  a  callosity,  which  may  cause  consid- 
erable annoyance. 

In  the  slight  degrees  and  early  stages  of  the  deformity  the  patient 
experiences  but  little  discomfort,  and  such  cases  are  not,  therefore, 
commonly  seen  by  the  surgeon  in  this  stage.  Later,  however,  locomo- 
tion becomes  difficult  and  painful. 

In  children  and  adolescents  the  deformity  can  generally  in  all  but 
the  severest  cases  be  corrected  by  simple  mechanical  treatment.  The 
toe  should  be  bandaged  or  strapped  to  a  rigid  splint,  cut  from  sheet 
tin  or  celluloid,  placed  under  the  toe  and  ball  of  the  foot.  In  children 
it  can  be  corrected  if  necessary  by  subcutaneous  section  of  the  con- 
tracted fasciae,  forcible  straightening,  and  fixation  in  a  straight  posi- 
tion by  means  of  splints  and  adhesive  plaster. 

After  correction  by  mechanical  means  the  toe  shows  a  tendency  to 
recontract  and  must  be  carefully  watched. 

In  severe  cases  it  is  possible  to  excise  the  prominent  phalangeal 
joint  of  the  toe  which  projects  upward,  and,  by  taking  out  sufficient 
bone  from  the  phalanges,  to  bring  two  bony  surfaces  together,  which 


POST-CALCANEAL  BURSITIS  405 

will  unite  and  keep  the  toe  straight  and  flat.     Subcutaneous  section 
of  the  shortened  fasciae  and  tendons  will  be  needed  in  the  severe  cases. 
It  also  occurs  at  times  in  connection  with  what  is  spoken  of  as 
contracted  foot.     The  tendons  and  fasciae  will  be  found  shortened. 

PAINFUL   HEEL. 

A  tender  and  painful  area  under  the  middle  of  the  heel  exists  at 
times,  and  is  spoken  of  sometimes  as  "  policeman's  heel."  It  seems  to 
be  associated  with  any  one  of  three  conditions : 

1.  The  radiograph  may  show  a  bony  spur  projecting  forward  from 
the  front  lower  edge  of  the  tuberosity  of  the  os  calcis.     This  may  or 
may  not  be  associated  with  exostoses  elsewhere  in  the  tarsal  bones. 

2.  It  may  be  associated  with  inflammation  of  the  bursa  under  the 
os  calcis. 

3.  It  may  be  the  expression  of  a  static  disturbance  (some  degree 
of  flat-foot),  in  which  the  chief  strain  falls  on  the  posterior  insertion 
of  the  plantar  fascia. 


FIG.  368. — Irritation  Exostoses  of  Os  Calcis. 

The  treatment  consists  in  the  relieving  the  os  calcis  from  pressure 
by  furnishing  a  thick  rubber  ring  pad  under  the  heel,  or  by  supporting 
the  sole  of  the  foot  so  that  less  pressure  comes  upon  the  heel. 

Local  hypersemia  treatment  is  also  beneficial. 

POST-CALCANEAL   BURSITIS. 

(Achillodynia.  Achillobursitis.  Anterior  Achillobnrsitis.) 

A  tender  swelling  at  the  junction  of  the  tendo  Achillis  and  os 
calcis  is  not  infrequently  met.  Plantar  flexion  of  the  foot  is  painful, 


406 


ORTHOPEDIC  SURGERY 


and  the  patient  walks  with  the  foot  everted  and  avoids  rising  on  the 
toes.  The  affection  may  be  unilateral  or  bilateral,  is  rather  resistant 
to  treatment,  and  liable  to  recur  when  nearly  well. 

It  is  caused  by  the  pressure  of  the  leather  at  the  back  of  the  boot 
pressing  on  the  end  of  the  os  calcis. 

For  treatment  it  is  necessary  to  remove  pressure  over  the  painful 


FIG.  369. — Radiogram  of  Irritation  Exostoses  of  Os  Calcis. 

area  by  splitting  the  back  of  the  boot  in  the  middle  line  behind  and 
setting  in  a  loose  piece  of  leather  between  the  spread  edges. 

In  resistant  and  very  acute  cases  the  application  of  a  plaster-of- 
Paris  bandage  to  the  leg  and  foot  will  be  necessary. 

An  inflammation  of  a  superficial  bursa  between  the  tendon  and 
the  skin  occasionally  occurs  from  pressure  of  the  boot  heel.  Its  treat- 
ment consists  in  the  removal  of  the  pressure,  and  in  severe  cases 
dissecting  out  the  bursa  if  inflamed;  in  some  instances  an  exostosis 
of  the  os  calcis  is  found  and  needs  to  be  removed. 

SYNOVITIS   OF  THE   TENDO   ACHILLIS. 

Symptoms  somewhat  like  those  described  occur  at  times  in  con- 
nection with  a  tenosynovitis  of-  the  tendo  Achillis,  which  is  shown  by 
the  usual  signs  of  swelling  of  the  sheath  of  the  tendon  above  the  os 
calcis,  tenderness  along  its  course,  and  silky  crepitus.  The  affection 
is  readily  controlled  by  rest  and  the  use  of  the  milder  class  of  measures 
mentioned  above. 


INDEX. 


ABBOTT, 

treatment  of  scoliosis,  238 
Abscess,  cold,  2 

in  tuberculous  disease  of  hip,  61 
treatment,  49,  82 

in  tuberculous  disease  of  knee,  95 

in  tuberculous  disease  of  spine,  10. 
20 

treatment,  49 

psoas,  21,  50 

retropharyngeal,   22,   50 
Achillobursitis,  405 
Achillodynia,   405 
Achondroplasia,    160 
Acquired    syphilis,    167 
Actinomycosis,    175 

of  spine,  175 
Albee     osteoplastic     operation     on     the 

spine,  49 

Amputation    for  knee-joint  disease,   105 
Angular  curvature  of  spine,  8;  and  see 

Tuberculous    disease   of   spine. 
Ankle,   excision   of,    108 

sprains  of,   142 

synovitis  of,   149 

tuberculous  disease  of,  106 
Ankylosis,  154 

formation  of  new  joints  in,   158 

treatment,   157 

Anterior  poliomyelitis,  267 ;  and  see  In- 
fantile paralysis 
Antiseptic  wax,  158 
Apparatus,   anterior  head  support,  33 

antero-posterior  support   for   Pott's 
disease,  33,  40 

bandages,  celluloid,  37 
plaster-of-Paris,  37 

bed-frame,  gas-pipe,  31 

bow-leg   irons,    197 

calliper,    for   anterior   poliomyelitis, 
289 

celluloid  jackets,  39,  40 

convalescent  hip  splint.  81 

equino-varus   splint,   357 

flat-foot  plates,  392 

for   anterior   poliomyelitis,   289,   291 

for  bow-legs,   197 

for    congenital    dislocation    of    hip, 

337 

for   equino-varus,   356 
for  hallux  valgus,  402 

407 


Apparatus    for    infantile    paralysis,    283 
284  to  294 

for  kyphosis,  248 

for  lateral  curvature  of  spine,  235 

for  Pott's  disease,  40 

for    round    shoulders,    248 

for   talipes    equino-varus,   354,   356, 

364 

for  talipes  equinus,  374 
gas-pipe   bed- frame,   31 
head   support,  33,  43 
anterior,  45 
oval   ring,  43 
hip     splints,     75,     76,     77,     79,     80, 

81 

knock-knee  brace,   191 
leather    splints    and    jackets,    40 
oval  ring  head  support,  43 
plaster-of- Paris   bandages,   36,   73 
removable  jackets,  39 
supporting    leg    brace    for    anterior 

poliomyelitis,   289,   291 
Thomas  calliper  splint,  285,  289 
hip  splint,  76,  87 
knee    splint,   96,   99,    100,    101 
torticollis  brace.  262 
traction  hip  splint,  78 
Aran-Duchenne  type  of  muscular  atro- 

phy,  3M 
Arthrectomy      in      knee-joint      disease, 

105 

Arthritis,  acute,  of  infants,   119 
ankylosing,   122 

chronic  rheumatic,  122 :  and  see  Ar- 
thritis   deformans,    122 
Arthritis   deformans,    122 
diagnosis,    129 
etioloerv.    124,    126,   128 
in  children.   132 
m  local  treatment,  no 
mechanical    treatment    of    deform- 
ities.   132 
of  hin.  i'6 

diagnosis,  n- 
etiology,   136 
pathology,   136 
symptoms,  137 
treatment,    137  .  i 
of  knee,  138          |Qf    , 
prognosis,    138  :< 
symptoms,    138 


408 


INDEX 


Arthritis  of  knee,  treatment,   139 
of   spine,    133 

diagnosis,   135 
etiology,    133 
pathology,    133 
prognosis,   135 
treatment,   135 
operative  treatment,   132 
pathology,   124 
prognosis,  125-129 
symptoms,    127 
treatment,    129 
varieties,    122 
Arthritis,    degenerative,     122,    124;    and 

see   Arthritis   defonnans 
Arthritis,    dry,    122;    and    see    Arthritis 
defonnans,    122 
gonorrhoea!,    120 
infectious,    1 19 
of   infants,   119 
proliferative,  122;  and  see  Arthritis 

defonnans 
rheumatic,    122;    and    see    Arthritis 

deformans 
stiffening,    124 
Arthropathy,  neural,   170 
neuropathic,   170 
of    hip,     1/3 

of    vertebral   column,    170 
spinal,    171 
tabetic,   i/o 

Articular   tuberculosis,    i  ;    and    see   Tu- 
berculosis of  joints 
Asymmetry,  unilateral,  318,  321 
Atrophy,   in  tuberculous  disease  of  hip, 
59,   67 

in   tuberculous  diser.se  of  knee,  92 
Attitude   in   rickets,   180 

in  tuberculous  disease  of  hip,  66 
in     tuberculous     disease     of     spine, 
13,  24 

RANDY   legs,    193:   and  sc?   Bow-legs 
Bartlett's    machine    for     reducing    con- 
genital   dislocation    of  hip,  336 
Bed-frame,   gas-pipe,   31 
Bone   grafting,    159 
Bone   defects,    158 

in    chronic   joint   diseases,    i^ 
Bones  and  joints,  syphilis  of,   165 

sinuses,    159 

tuberculosis   of,    i 

tumors   of,    164 
Bow-legs,   193 

anterior  curvature   in,  195 
treatment,    200 

apparatus    for,    197 

causation,    194 

diagnosis,    196 

occurrence,    194 


Bow-legs,  osteoclasis,   197 
osteotomy,    199 
prognosis,    196 
treatment,    196 

expectant,    196 

mechanical,   197 

operative,   197 
Bunion,   402 

Bursitis  of   deep  prepatellar  bursa,  153 
of  hip,  151 
of  knee,   151 
of  shoulder,   149,   154 
treatment,   150 
prepatellar,    151 

deep,  153 
post-calcaneal,   405 

CALLIPER  splint,  285,  289 

Calot's   method,    in    tuberculous    disease 

of  the  spine,  33 

Caput    obstipum,    256 ;    and    see    Torti- 
collis 
Caries  of  spine,  8;  and  see  Tuberculous 

disease  of  spine 
Cartilages,   loose,    146 
Casts   of   foot,  392 

for    flat-foot    plates,    392 
Cerebral  paralysis,  301  ;  and  see  Spastic 

paralysis 

Charcot's   disease  of   hip,   173 
joint    disease,    170 
of    spine,    173 
Chest,    rhachitic,    179 
Chicken-breast,   252 
Children,   arthritis   deformans   in,   132 
Chondrodystrophia    fcetalis,    160 
Club-foot,  349'  and  see  Talipes  equino- 

varus 

Club-hand,  380 
Cold   abscess,  2 

Congenital  dislocation  of  elbow,  347 
of   hip,  323 
of  knee.  345 
of    patella,   346 
of   shoulder,  346 
of   wrist,   348 
elevation    of   scapula,   254 
Congenital  syphilis,  165 
torticollis,    256,    259 
Contracted    foot,   400 
Convalescent   hip   splint,  81 
Coxa  valga,  208 
Coxa  vara,  69,  201 
diagnosis,   205 
etiology,   201 
osteotomy  for,  206-207 
prognosis,  205 
splints,    206 
symptoms,   204 
traumatic,    202-203 


INDEX 


409 


Coxa  vara,  traumatic,  treatment,  208 

treatment,  206 
Coxitis,  senile,  136 
Cubitus  valgus,  347 

varus,  347 
Cysts  of  knee,   149 

DEFORMITIES  of  spine  and  thorax,  243- 

252 

Degenerative   ataxia,   314 
Dislocation    of    hip,   congenital,    323 
of   patella,   habitual,    161 
of  semilunar  cartilages,  146 
of    shoulder,    habitual,    163 
Dislocations,   congenital,   323 

from   infantile   paralysis,  276 
Distribution      of      chronic      tuberculous 

joint  diseases,  4 

Dry    arthritis,    122 ;    and    see    Arthritis 
deformans 

ECHIXOCOCCUS  cysts  of   spine,   175 
Elbow,  congenital  dislocation  of,  347 

synovitis  of,  151 

tennis,    151 

tuberculous   disease   of,    no 
Epiphyseal  strains,   140 
Epiphysis   of    femur,   separation   of,   68 
Equino-varus   splint,  356 
Erb's  type  of  muscular   atrophy,  314 
Excision      for     anterior     poliomyelitis, 
300 

of  ankle,  108 

of  knee,   103 

of  shoulder,   no 

FAMILY  ataxia,  314 

Feet,   examination   of,   388 

Femur,  sarcoma  of,   165 

separation  of  epiphyses  of,  68 
Fissures  and  fractures  near  joints,  153 
Fixation   treatment  of   tuberculous  dis- 
ease of  hip,  69 

of     tuberculous     disease    of     knee, 

96,  99 
Flat-foot,   381 

causation,  383 

diagnosis,   388 

forcible  correction   of,  396 

pathological   anatomy,   382 

plates   for,  392 

prognosis,   389 

symptoms,  386 

treatment,    389 

varieties,  383 

Flattening  of  head  of  femur,  69 
Floating  bodies   in  joints,    146 
Foetal  rickets,   160 
Foot,  casts  of,  to  make,  389 


Forcible  correction   in  tuberculous  dis- 
ease of  the  spine,  46 
Fracture,  sprain,  140 
Fractures  and  fissures  near  joints,   153 
Fragilitas  ossium,   160 
Friedreich's  disease,  315 
Functional  affections  of  joints,  318 

of  spine,  320 
Funnel  chest,  253 

GANT'S  osteotomy  of  hip,  83 

Genu  valgum,  182;  and  see  Knock-knee 

varum,   193 ;  and  see  Bow-legs 
Genuclast,    102 
Gonorrhoeal   arthritis,    120 
Gout,    169 

rheumatic,    122;    and    see    Arthritis 
deformans 

HEMOPHILIA,  joint  lesions  in,  173 
Hallux   rigidus,  403 
valgus,  401 

toe-post  for,  403 
varus,  403 
Hammer  toe,  404 
Harrison's   sulcus,   179 
Head   supports    in   treatment  of   tuber- 
culous  disease  of  spine,  43 
Heberden's  nodes,   127 
Heel,  painful,  405 

policeman's,  405 
Hereditary  ataxia,  315 
Key's    internal    derangement    of    knee, 
146 

treatment,  148 
Hibbs     osteoplastic    operation    on     the 

spine,  48 

Hip,  arthritis  deformans  of,   136 
arthropathy    of,    173 
bursitis    of,    151 
Charcot's   disease  of,   173 
congenital  dislocation  of,  67,  323 
accidents  in  treatment  of,  337 
after-treatment,  338 
diagnosis,  327 
etiology,  323 
frequency  of,  323 
osteotomy  in,  342 
pathology,   324 
prognosis,  330 

after-treatment,  343 
reduction    by    manipulation    337 
by    open    incision,    342 
with     aid     of     mechanical 

force,  336 
symptoms,  327 
treatment.    330 

accidents   in.  337 
summary,  344 


4io 


INDEX 


Hip   disease,   52;    and    see   Tuberculous 
disease   of   hip 

dislocation    of,    congenital,    323 
diagnosis,   2-7 
etiology,  323 
symptoms,    327 
Trendelenburg's  sign,  329 
prognosis,   330 
treatment,  330 
after-treatment,  338 
excision   of,   t>7 
inflammation,    acute    infectious,    of, 

68 

malignant  disease  of,  165 
osteomyelitis  of,  68,  118 
ostitis,  chronic  articular,  of,  52;  and 

see  Tuberculous  disease  of  hip 
sarcoma   of,   70 
sprains   of,    141 
synovitis  of,  68,   143 
tuberculous  disease  of,  52 
Hip-joint    disease,    52;    and   see    Tuber- 
culous disease  of  hip 
Hip-splint,   convalescent,  81 
Thomas,  77 

traction  and  abduction,  77 
Hip,  unilateral  asymmetry  of,  318,  321 
Hollow  foot,  376;  and  see  Talipes  cavus 
Housemaid's   knee,    151 
Hydrops,    intermittent,    142 
Hypenesthetic  spine,  27 
Hypertrophy  of  synovial  villi,  144 
Hysterical  joints,  69,  318 

INFANTILE  paralysis,  267 

apparatus  for,  283,  284  to  294 
arthrodesis    in,   299 
bone  operations  in,  300 
calliper   apparatus    for,   285,   289 
contraction?,  treatment,  292 

Soutter's   operation   for,   294 
deformities  in,  270,  274 

prevention  of,  281 

treatment,  292 
diagnosis,   277 
dislocations  from,  276 
electrical    reactions   in,   277 
electricity    in    treatment   of,   283 
etiology,  267 
excision   for,  300 
heat   in   treatment  of,   285 
lateral    curvature    in,   275 
lordosis   in,   272 
massage   in,  283 
muscle  and  tendon  transference  in, 

295 
muscle    training    in     treatment    of, 

282 

nerve  grafting   in,  300 
osteotomy    for,    300 


Infantile  paralysis,  paralysis  of  leg  and 
thigh   muscles   in,  271 

apparatus    for,  291 
physical    therapy    in,   283 
plaster  bandages   for,  293 
prognosis,    279 
silk  ligaments   in,  299 
symptoms,  268 

talipes   calcaneo-valgus    in,   274,   292 
talipes    calcaneus    in,   274,   292 
equino-varus  in,  293 
equinus    in,  292 
tendon   transference   in,  295 
treatment,   280 

mechanical,    286 
operative,    295 

Whitman's  operation  for,  300 
Infants,   arthritis   of,    119 
Infectious  arthritis  and  synovitis,  119 
Intermittent   synovitis,    142 
In-toe,  402 

Ischasmic   paralysis,  317 
treatment,   283 

method  of  Robert  Jones,  283 

JOINT  affections  in  gout,  169 
in   luemophilia,    171 
in    scurvy,    174 

disease,   Charcot's,   173 

mice,   144 
Joints,  cold  abscess  of,  2 

fractures   and   fissures   near,   153 

functional   affections    of,   318 

hysterical,   318 

inflammation    of,    119 

loose  bodies  in,   144 

syphilis  of,    168 

tuberculous  disease  of,  I 

tumor    of,    164 

KNEE,   arthritis   deformans   of,    138 
bursitis  of,   149,   151 
congenital   dislocation  of,  345 
cysts    of,    149 
dislocation   of   semilunar   cartilages, 

146 

excision  of,  103 

forcible  correction  of  flexion  of,  98 
housemaid's,    151 
internal    derangement,    146 
lipoma   of,    146 
loose  bodies  in.   146 
osteomyelitis  of  the  knee  joint,   117 
pain   in,  in  hip  disease,  56 
sprains   of,   141 

stiff,  operation  to  correct,  104 
synovitis    of,    143 
trigger,  149 
tuberculous   disease   of,  91 


INDEX 


411 


Knee,  tumor  albus,  91 ;  and  see  Tuber- 
culous disease  of  knee 
Knee-joint    disease,   69,   91 
Knees,  loose,  185 
Knee   splint,   jointed,  98 

Thomas,  96,  99,  101 
Knock-knee,    182 

brace   for,   191 

diagnosis,   187 

etiology,    182 

gait   in,    184 

loose  knees  in,   185 

manipulation,    in   treatment,    190 

measurement   of    deformity   in,    186 

mechanical    production   of,    183 

occurrence,   182 

osteoclasis    for,    192 

osteotomy  for,  191 

prognosis,    187 

symptoms,    183 

treatment,  188 

ambulatory,    190 
expectant,   188 
mechanical,    190 
operative,    190 
Kyphosis,  243 ;  and  see  Round  shoulders 

apparatus   for,  248 

static,    from    occupation,   248 

LAMINECTOMY,  51 

Landouzy-Dejerine    type     of    muscular 

atrophy,  314 
Lateral  curvature  of  spine,  212 

Abbott  jackets  in,  238 

apparatus  for,  235 

cervical,  221 

curves   in,  220 

deformity  in,  219 

definition,  212 

diagnosis,   227 

difference  in  length  of  legs  in, 
224 

displacement  of  abdominal  vis- 
cera  in,   215 

distortion  of  pelvis  in,  214 

dorsal,  222 

etiology,  215,  226 

examination,   227 

exercises    in,   234 

frequency  of,  212 

jackets   for,  236 

lumbar,   22.1 

methods    of    recording,    229 

pain    in,   219 

paralytic.  225 

pathology,    2T2 

plaster  jacket  for,  236 

prevention  of,  230 

prognosis,    229 

rhachitic,   224 


Lateral  curvature  of  spine,  rotation  in, 
223 

symptoms,  217 
torticollis  in,  225 
treatment,  232 

corrective  measures,  235 
operative,  242 
postural,  233 
varieties  of,  224 

Lateral  deviation  of  spine  in  Pott's  dis- 
ease, 15 

Lipoma  of  knee,  146 
Little's    disease,    301 ;    and    see    Spastic 

paralysis 
Loose  bodies  in  joints,  144 

treatment  of,   145 
knees,   185 
Lordosis,  249 

Lumbar  abscess  in  Pott's  disease,  21 
Pott's  disease,  68 

MACEWEN'S  osteotomy  for  knock-knee, 
191 

Madelung's    deformity    cf    wrist,   348 

Malignant  disease  of   hip,    165 
of  spine,  164 

Malpositions  of  limb,  in  tuberculous  dis- 
ease of  hip,  59 

in   tuberculous   disease  of  knee,  92 

Metatarsalgia,   399 

Morbus  coxae ;  see  Tuberculous  disease 
of  hip 

Movable  bodies  in  joints,   146 

Muscular  pseudo-hypertrophy,  312,  and 
see  Pseudo-hypertrophic  muscular 
paralysis 

Myositis   ossificans,    175 

NERVOUS     system,     pathological     condi- 
tions of,  170 
Neural   arthropathy,   170 
Neuromimesis ;  see  Functional  affections 

of  joints 

Neuropathic  arthropathy,   170 
New  joints,  formation  of,  in  ankylosis. 

,158 
Night  cries  in  hip  disease,  58 

treatment   of,   82 
Nodes,   Heberden's,    127 

OBSTETRICAI.  paralysis.  316 

treatment,  316 

Orthopedic  surgery,  scope  of,  i 
(Jsteoarthritis,    122;    and    see    Arthritis 
deformans 

of  spine,  133 
Osteoarthropathy  of  hereditary  syphilis, 

165 

secondary  hypertrophic,  174 
Osteochondritis  of  Parrot,  165 


INDEX 


Osteoclasis,   for   bow-legs,    197 

for   knock-knee,    192 
Osteoclast,    Ri/./.oli's,   197 
Osteomalacia,    160 
Osteomyelitis,   infectious,    114 
diagnosis,    115 
etiology,    114 
pathology,    114 
prognosis,    116 
symptoms,    115 
treatment,     1 16 
Osteomyelitis   of   hip,   67,    118 

of    spine,    117 

Osteotomy     for    anterior    poliomyelitis, 
300 

for  bow-legs,    190 

for    congenital    dislocation    of    hip, 

342 

for  coxa  vara,  206 
for  deformity  at  knee,   104 
for  knock-knee,  191 
for    tuberculous    disease    of    hip,   83 
for  tuberculous  disease  of  knee,  104 
Ostitis    deformans,    169 
etiology,   170 
prognosis,    171 
symptoms,    170 
Other    deformities    of    the    spine    and 

thorax,   2^3 
Out-knee,    199:    and   see   Bow-legs 

FACET'S   disease,   169 
Painful    heel,   .105 

Paralysis,  cerebral,  301  ;  and  see  Spastic 
paralysis 

infantile,     267;     and     see     Infantile 

paralysis 

in   Pott's  disease,   10,   18,  51 
ischcTtnic,    317 
obstetrical,  316 

pseudo-hypertrophic    muscular,    312 
spastic,   30 T 
Volkmann's,  317 
Parrot's   disease,    165 
Patella,  congenital  absence  of,  346 

dislocation   of.  346 
dislocation   of,  habitual,   161 
slipping.   161 

Pathological   conditions   of   the  nervous 
system,    Charcot's    joint    disease,    170 
arthropathy  of   the  hip,    173 
arthropathv    of    the    vertebral    col- 
umn.  173 

Pectus  carinatum,  252 
excavatum,   253 
gallinatum,  252 

Periarthritis   of   shoulder,   1^9 
Pes  arcuatus,  376;  and  see  Talipes  cavus 
calcaneus,  374 :  and  see  Talipes  cal- 
caneus 


Pes  cavus,  376 ;   and  see  Talipes  cavus 
contortus,     349;     and     see     Talipes 

equino-varus 
equinus,      375;      and      see      Talipes 

equinus 
excavatus,    376;    and     sec     Talipes 

cavus 

planus,  379;  and  see  Flat-foot 
Pigeon   breast,   252 

toe,   403 

Plantar   fascia,  division  of,  361 
Plaster,  37 

Plaster  casts  of    foot,   to   make,  392 
jackets,    application    of,    33,    34,    35, 

36 

removable,   36 

Plaster-of-Paris    bandages,    37 
Policeman's  heel,  405 
Poliomyelitis,  anterior,  267 ;  and  see  In- 
fantile paralysis 
Porencephalus,   305 
Pott's   disease,  8:  and  see  Tuberculous 

disease   of    spine 
Prepatellar  bursitis,   151 
Progressive   muscular   atrophy,  314 

types   of,  314 
Pseudoarthrosis,    118 
Pseudo-hypertrophic  muscular  paralysis, 
312 

etiology,   312 
pathology,    312 
prognosis,  313 
symptoms,   312 
talipes  equinus  in,  313 
treatment,  313 
Psoas   abscess,  21 
treatment,   50 

REPAIR   of   tendons,  363 
Retropharyngeal    abscess,   22,    50 
Rhachitic    curves    in    upper    extremity, 

200 

Rhachitics,   177:  and  see  Rickets 
Rheumatic    arthritis,    chronic,    122;    and 
see  Arthritis  deformans 

gout,     122:    and    see    Arthritis    de- 
formans 

Rheumatism,  chronic  articular,  122;  and 
see   Arthritis   deformans 

gonorrhoeal,   120 
Rickets,    177 

adolescent,    177 

attitude    in,    180 

causation,    177 

changes   in   bones,   178 

chest  in,   179 

curves    in    arm,    180 

diagnosis,    182 

foetal,   160 

flat-foot  in,  181 


INDEX 


413 


Rickets,   fontanelles   in,   179 

Harrison's   sulcus,   179 

head  in,  179 

occurrence  and  etiology,  177 

pelvic  deformity   in,    180 

prognosis,   182 

spine  in,  179 

treatment,    182 
Rigidity  of  spine,  133 
Rizzoli's  osteoclast,  197 
Round  shoulders,  243 

apparatus    for,  243 

prognosis,  246 

treatment,  246 

SACRO-ILIAC   articulation,    relaxation   of, 

164 

Sacro-iliac  disease,   112 
Scapula,   congenital  elevation   of,   254 
Scoliosis,  212 :  and  see  Lateral  curvature 

of  spine 

Scurvy,  joint  affections   in,   174 
Semilunar  cartilages,  dislocation  of,  146 

treatment.    148 
Senile   coxitis,    136 

Separation   of   epiphyses   of   femur,   70 
Shortening    in    tuberculous    disease    of 

hip,  62,  65,  84 
Shoulder,  bursitis  of,  149,  154 

congenital   dislocation   of,  346 

excision  of,  no 

habitual  dislocation  of,  163 

obstetrical  paralysis  of,  316 

periarthritis   of,   149 

synovitis   of,   149 

tuberculous  disease  of,  109 
Spastic  paralysis,  301 

after-treatment,  310 

atrophy    in,    303 

condition  of  muscles  in,  304 

contractures   in,   303 

diagnosis,  305 

mental   defects   in,   302 

pathology,   305 

prognosis,  306 

symptoms,    301 

tendon  transference   for,  310 

treatment,  306 

operative,  307,  311 
Spinal   arthropathy,    170 
Spine,  actinomycosis  of,   175 

ankylosing     inflammation     of,     133; 
and  see  Spondylitis  deformans 

caries  of,  8 :  and  see  Tuberculous 
disease   of    spine 

echinococcus  cysts  of,  175 

functional   affection   of,  320 

hyperresthetic,   27 

hysterical.   320 

irritable,  320 


Spine,  lateral  curvature  of,  212 
malignant  disease  of,  28,   164 
osteoarthritis  of,  133 
osteomyelitis    of,   28,    117 
rhachitic  deformity  of,  27 
rigidity   of,    133 
spondylitis  deformans  of,  29 
sprains  of,    141 
tuberculous   disease  of,  8 
typhoid,    118 

Spondylitis   deformans,    133 
Spondylolisthesis,    23,    251 
etiology,  251 
pathology,  251 
symptoms,  251 
treatment,  251 
Sprain   fractures,   140 
Sprains,    140 

of  ankle,   142 
of    hip,    141 
of  knee,   141 
of   spine,    141 
Sprengel's  deformity,  254 
Still's   disease,    132 

Subluxation  of  wrist,  spontaneous,  348 
Symphysis   pubis,   relaxation  of,   164 
Synovial  villi,  hypertrophy  of,  144 
Synovitis,   68 

chronic,  144 
intermittent,   142 
gonorrhoeal.    120 
etiology,   121 
pathology,   120 
treatment,    121 
varieties,    120 
infectious,   119 
etiology,    119 
pathology,   1 19 
symptoms,    120 
treatment,   1 20 
of  ankle,  149 
of  elbow,   151 
of  hip,  67,   143 
of  knee,  M3 
of  shoulder,   149 
of  tendo  Achillis,  406 
of  wrist,    151 
Syphilis,  acquired,   167 

circumscribed  periostitis  in,  167 

congenital,  165 

dactylitis,  167 

diffuse  periostitis,  167 

diffuse  gummatous  osteomyelitis, 

167 
local    gummatous   osteomyelitis, 

167 

of  spine.   160 
of  bones  and  joints,  165 
of  the  joints.   168 
ossifying  periostitis,  167 


INDEX 


TABETIC  arthropathy,   170 
Talipes,    349 

calcancus,    374 
cavus,  376 
equino-varus,  349 

apparatus    for,    354,    356,    364 
diagnosis,   351 
etiology,    351 

forcible   manipulation,  365 
frequency,  349 
manual    manipulation,   354 
mechanical    correction,   354 
open    incision,   364 
operative    treatment,    359,    364 
osteotomy,    367,    368 
pathological   anatomy,   349 
plantar    fascia,   division   of,   361 
plaster-of-Paris    bandages,    354 
prognosis,   352 
relapses,    371 

repair  of  divided  tendons,  363 
splint  for,  357 
symptoms,  351 
tenotomy,  359 
treatment,  353 
equinus,  373 

apparatus    for,   374 
valgus,    375 
varus,  376 
Tendo    Achillis,    synovitis    of,   406 

tenotomy  of,  360 

Tendon     transference     in     spastic     pa- 
ralysis, 310 

in   infantile  paralysis,  295 
Tendons,   divided,   repair  of,   363 
Tennis    elbow,    151 
Tenosynovitis  of  shoulder,  149 

of   wrist,    151 
Tenotomy   in   spastic   paralysis,   307 

of    tendo    Achillis,    360 
Thomas    calliper    splint,    98,     101,    285, 
289 

hip  splint,  76,  77,  78,  Co,  87 
knee   splint,   99,    100,    101 
Thorax,   deformities    of,   252 
Tibia,  lesions  of  tubercle  of,  141 
Toe-post,    401 
Torticollis,    256 

acquired,  257,  259 
apparatus   for,  263 
brace,   262 

congenital  256,  259,  263 
diagnosis,  260 
etiology,    256 
pathology,   258 
physiological,   257 
posterior,    264 
prognosis,  261 
spasmodic,  257,  260 
treatment,  265 


Torticollis,  symptoms,  259 

treatment,  262,  263 

operative,  263,  266 
Traction  hip  splint,  75,  82 
Traumatic  coxa  vara,  202 
Trigger  knee,  149 

Tuberculosis,   articular,   i  ;   and  see  Tu- 
berculous  disease  of  joints 

of   bone,    i 

of    vertebra?,    8;    and    see    Tuber- 
culous  disease  of   spine 
Tuberculous    disease   of   ankle,    106 

diagnosis,    106 

excision,    109 

mechanical   treatment,    107 

operative  treatment,   108 

prognosis,    107 

symptoms,     106 
Tuberculous   disease   of   bone,   I 

diagnosis,    5 

diagnosis  by  means  of  tuberculin,  5 

diagnosis  by  means   of  X-ray,  5 

distribution    of,   4 

etiology,    3 

pathology,    i 

prognosis,   5 

treatment,   6 
outdoor,   7 
heliotherapy,  7 
Tuberculous   disease  of   elbow,   no 

symptoms,    1 10 

treatment,    112 
Tuberculous   disease  of  hip,  52 

abduction   in,  75 

abscess  in,  61,  89 

treatment  of,  49,  82 

after-treatment,   85 

ankylosis   in,   87 

atrophy   in,   59,  67 

attitudes    in,    66 

cause   of   death,   71 

clinical   history,   54 

complications,   treatment    of,   82 

crutches    in,   80 

curetting   and    drainage    in,    87 

deformity   in,   62,  65 
treatment    of,    82 

diagnosis,  63 

differential    diagnosis,   68 

double,  62,   86 

duration  of  treatment,  71 

early    symptoms.    54 

examination   in,   64 

excision,    87 

fixation,   72 

functional    results,   71 

general   condition    in,   62 

lameness  in,  56,  66 

length  of  time  for  treatment,  71 

limping   in,   54 


INDEX 


Tuberculous    disease    of    hip,    malposi- 
tions of  limb  in,  59 
mortality,  71 
muscular   fixation   in,   58 

spasm  in,  58,  63 
night-cries    in,    58 

treatment,   82 
operative  treatment,  87 
osteotomy,    83 
pain   in,   56 
pathology,    52 
periarticular    symptoms,    6l 
plaster    bandage,    73 
prognosis,    71 
protection  in,  81 
recovery,  71 

recumbent  treatment,  76,  83 
relapses,   82 

shortening  in,  62,  65,  85 
summary  of  treatment,  88 
swelling   in,   67 
symptoms,   54 
Thomas   splint  in,  87 
traction,  75 

splint  in,  75,  82 

straps  in,  77 
treatment,  72.  89 

of   complications,  82 

operative,   87 

summary    of,    88 
Tuberculous   disease  of  joints,  I 
diagnosis,  5 
distribution  of,  4 
etiology,    3 
pathology,  i 
prognosis,  5 
treatment,  6 

Tuberculous   disease  of  knee,  91 
abscess    in,   94 

treatment,   102 
amputation   for,   103,    105 
ankylosis,    104 
arthrectomy,  103,  105 
atrophy  in,  92 
calliper  splint,  98,   101 
clinical  history,  91 
complications,   treatment   of,   98 
conservative    treatment,    95 
definition,  91 
deformity,  92 

treatment,  98 
diagnosis,  94 
excision,  103,  104 
fixation,  96 

bandages  in,  99 

forcible  correction  of  flexion,  98 
genuclast,   102 
knock-knee   in,  QI 
heat,   92 
lameness,  92 


Tuberculous   disease   of   knee,  malposi- 
tion of  limb  in,  92 
muscular  fixation,  92 
operative  treatment,  103,  104 
pain,   92 
prognosis,  94 
protection  in,  96 
rotation  of  tibia,  94 
swelling  in,  91 

Thomas   splint,  96,  99,   100,   101 
treatment,  95,  102,  103 
Tuberculous  disease  of  sacro-iliac  joint, 

112 
Tuberculous    disease    of    shoulder,    109 

symptoms,    109 

treatment,    no 

Tuberculous  disease  of  spine,  8 
abscess  in,  10,  20 

treatment  of,  49 
ambulatory  treatment,  33 
antero-posterior    support,    43 
apparatus    for   correction,   40 
application    of   bandages,   39 
attitude  in,   13,  24 
bed-frame  for,  31 
Calot's   jacket,  34 
celluloid    bandages,   39 
cervical,  24 

abscess,   21 

operations   for,  46 
collars,   44 
complications.    18 
deformity,   16 

correction   of,   46 

tracings  of,  17,  29,  47,  49 
diagnosis.    22 
differential  diagnosis,  27 
dorsal,    25 

abscess,  21.  49 

operation   for,  49 
etiologv,    u,    12 
forcible  correction,  46 
gait    in.    24 
head  supports  in,  43,  45 

traction,    32 
laminectomy  in,  51 
lateral  deviation  in,  15 
leather  jackets,  40 
localization,  IT 
lumbar,  25,  68 

abscess,  21,  49 

diagnosis  of,  26 

operation    for,   49 
mortality,   29 
muscular    stiffness,   23 
occurrence,  n 

osteoplastic   operations   in,   48 
pain  in,   15 
paralysis  in,  18 

pathology,  10 


416 


IXDEX 


Tuberculous  disease  of  spine,  paralysis 
in,  treatment,  51 
pathology,    8 
plaster   jackets,    33 
plaster-of-Paris    bandages,    37 
prognosis,   29 
psoas  abscess,  21 

treatment,   49 

psoas   contraction,  treatment,   50 
recumbency-treatment,   30 
removable   jackets,   35.   39 
retropharyngeal   abscess,   22 

treatment,   49 
spontaneous   cure   in,    17 
suspension   in,  33 
symptoms,    12 
temperature    in,    18 
tracings  of  deformity,   17,  47 
traction    in,    32 
treatment.    30 

ambulatory,    33 

apparatus    for,    40 

application    of   bandages,   39 

by  Calot's  method,  34 

by    collars,    44 

by    forcible   correction,   46 

by  head   supports,  43 

by   plaster   jackets,    33 

by  plaster-of-Paris  bandages,  37 


Tuberculous  disease  of  spine,  treatment, 
by  recumbency,  30,  32 
by  steel  appliances,  40 
operative  measures,  46,  47,  48, 

49 

Albec's    operation,    49 
Hibbs'  operation,  48 

Tuberculous   disease  of   wrist,   112 
symptoms,  112 
treatment,    112 

Tumor  albus,  91  :  and  see  Tuberculous 
disease  of  knee 

Tumors  of  bones  and  joints,   164 

Typhoid  spine,   1 18 

UNILATERAL   asymmetry,  318,  321 

YEKTEP.RAL  column,  arthropathy  of,   170 
Volkmann's   paralysis,  317 

WHITE    swelling,    91  :    and    see    Tuber- 
culous  disease  of  knee 

Wrist,   congenital   dislocation    of,   348 
Madelung's    deformity    of,    348 
spontaneous   subluxation   of,  348 
synovitis   of,    151 
tenosynovitis  of,   151 
tuberculous   disease  of,   112 

Wry-neck,   256 ;   and   see   Torticollis 


Date  Due 


IN  U.  S.  A. 


000510014 


Bradford . 


WE  168 
B  799  o 
1915 
Orthopedic  surgery 


WE  168 
B  799  o 
1915 
Bradford.  Orthopedic  surgery 


UCI  CCM  LIBRARY 


